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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM []Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL_ /?ncil Q5m7fiQ7 ;:nM Iracocr•Trnrae CVDIOCC i Vim A" 0M^&• n...,- 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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. .r MINI a4HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE OWE DATEOq SC Received JOBADDRESS L-�TJ CITY%LIPfSG61DN, C0V•Q93ZO0y --77��nn p J�// CROSS STREET APN LSA' MI' 1SO- IiIO PARCEL $RE�LA�1ND USE APP�L^ICATION# OWNER Dahl tuhMKON PHONE' 4p-'[" �QJ•� OWNER ADDRESS Arb�s onNat tt'IIf/ CITY/STATElZIP �� QN. ca 4.�31�0 CONTRACTOR PHONE - i Z CONTRACTORADDRESS iii ., CITY/STATEr U CfD GUI. g53y 7 (•�/f�/ n C-57 WELL DRILLING LICENSE NUMBER lY W A �� EXPIRATION DATE • 31. 7j�I PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CnY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol, Tobacco and Firearms . Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff.Coroner Explosives Application and Permit License Number Expiration Dale ❑ California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAIL$ ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other t ,^ �N(/( Well Log copy attached ❑ Yes (��l] No Grout Seal ❑ No ❑ Yes _ It below ground surface (bgs) Hole Diameter I rC-diYf/efr�f3-� Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing it bgs Diameter of Conductor Casing inches Well Casing Diameter, lin Inches Total Depth O r_ft Depth to Water..4 I1 - It Depth of Casing it bgs I a DESTRUCTION SPECIFICATION I O Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to it bgs Well casing to be perforated by one of the following methods: from It bgs to it bgs ❑ Mills Knife Number of cuts every tt and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other S al ng Material r' Neat Cement (94 lb bag/5-6 gal water) `I Sand Cement sack mW7 gal water Bentonite Pellets Bentonite (20% olids) a Manufacturer Spec % solids_% Name _ Specs on File J Specs Submitted Place ant Method Pumped n Free Fall f n Other Seal Completion Complete with Mushroom Cap _ � tt bgs Li Complete to Existing Surface Pa 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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. .r MINI a4HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE OWE DATEOq Application Accepted By - Destruction Inspection By COMMENTS _ _I�Q DEPARTMENT USE ONLY Area Employee ID# 11 PE SC Received Check#/ Amount Permit/ Codes Info Cash Remitted Date Service Re uest# Invoice # WeII ID# I a i i -- — — — VIVA FF I Application Accepted By - Destruction Inspection By COMMENTS _ _I�Q DEPARTMENT USE ONLY Area Employee ID# 11 PE SC Received Check#/ Amount Permit/ Codes Info Cash Remitted Date Service Re uest# Invoice # WeII ID# HD 43-08 WELL DESTRUCTION PERMIT FENr AFD 3 ® 20Z0 QC)//U C FP EN OAS rY T ART MENT