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WELL DESTRUCTION PERMIT 01 PUI rATERSYSTEM❑YesNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202-(20468-3420 NON-REFUNDABLE,PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED y JOB ADDRESS N IOWA WeS+ CITU/ZIP CROSS STREET d' W111,0W61APN la I—CO O-LO PARCEL SIZE_LAND USE APPLICATION# e OWNER- 'I�'/�S'- A±b96bPHONE 1 f_ WNER ADDRESS 1 M CITY/STATE/ZIP n(j I.J, (,--r' Q� LLLiii CONTRACTOR Z PHONE O '/IO 5-` la` CONTRACTOR ADDRESS CITY/STATE/ZIP '041KU� , CA q (of 2- I ❑ C-57WELLDRH.t.ING LICENSENUMBER EXPIRATION DATE ,LIT PERFORATION CONTRACTORyI � W111610 R ?d I PHONE L�} PERFORATION CONTRACTOR ADDRESS ..-P.O. 1JO�C �,7 CITYISTATE/ZIP , ` R4 `4 f(y C-57 Well Drilling License Number Expiration Date / ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date f ❑ 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 ❑ Dry ❑ 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 'v*Yes ❑ No Grout Seal ❑ No W Yes ft below ground surface(bgs) Hole Diameter inches �a \ Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches I Well Casing Diameter 2- inches Total Depth ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile �[; `e��In co �nd boosters wtth'roOjectil�every ft ❑ without projectile AT Other r �A =041 C Sealing Material eat Cement(94/b bag/5-6 gal water) 11Sand C ent sack mix/7 gal water ❑ Bentonite Pellets ❑ Bentoulte 0%solids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File ❑ Specs Submitted Placement Method' ❑ Free Fall 13 Other Seal Com,------ /❑ Complete with Mushroom Cap ft 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE IZ i if i ------ 19 r I T P R'}AMX- T USE O N.L Application Accepted By t t" —,--I Date y/ w� Area Destruction Inspon By Date 7 / Employee ID# I-- COMMENT % •f p7 �- 6 PESC EReceived Check#/ Amount Permit/ Codes Into B Cash Remitted Date ServiceRequest#EEInvoice# WellID# t: 2402 CK1 �l> EHD 43.02 W8 Well Deswcuna P—a 127/2005