SU0013967 - Laserfiche WebLink

Home Browse Search

IAA: �� WELL DESTRUCTION PERMIT 0-17. /;,,:-+' PUBLIC WATER SYSTEM ❑Yes []No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT �/ CALL 202 S53-76:,7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / I��T r" CITU/ZIP -r� r", ��'J -_�• CROSS STREETyyO -✓f T n 4 L AP I V, ,J C O L /J PARCEL SIZE 37YLANDD USEAPPLICATION# c OWNER �r1E PHONE i OWNER ADDRESS Y„- CITY/STATE/ZIP CONTRACTOR'^ tr �'S '�/�.0 PHONE ,� CONTRACTOR ADDRESS �"1L f CrTY/STATEIZIP O O fI r !' .Z C-57 WELL DRILLING LICENSE NUMBER t7 C EXPIRATION DATE �J C PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION �ogzry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes '11!�No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes X No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter/inches Total Depth_1_,Y ft Depth to Water it Depth of Casing ft bgs DESTRUCTION SPECIFICATION n �',S Sealing Material from i S ft bgs to L ft bgs Filler Material'3�N�d A/ G /'from it bgs to ft bgs Well casing to be perforated by one of the following methods: from it bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles everyit ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water):. Sand Cement (I sack mix/7 gal water �,,Aentonite Pellets , Bentonite(20%solids) - Manufacturer Spec%solids_% Name Specs on File Spew Submitted Placement Method Pumped >'Free Fall Other Seal Completion _ Complete With Mushroom Cap Y it bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI .�,U7�/+1,24y/i'DUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE—Z41Wy TITLE C/ "— DATE �td �( S r � J \ Z- o '3 0 LoTc. tx � /-/o v. L-)h'oCy p RFCE E aQ(/3 i da L)Siv SgNJAPR p 7 TN OROMNCOq�lk (� DEPARTMENT USE ON Y q/V LC i C Date 7 Area Application Accepted B `_ Destruction Inspection B — ' Date ! Employee ID#_ COMMENTS 4i ;2LZOLL 22 PE Sc Received Che Amount Date PermiU Invoice# Well ID# Codes Into B ash Remitted Service Request# eb 7,6 9 EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07