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WELL DESTRUCTION PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />JOB AODRE-_;z <br />CROSS STREET <br />5._ 4 <br />I� <br />OWNER o!i✓-, JC er, 4 <br />OWNER ADDRESS <br />CONTRACTOR A <br />CONTRACTOR ADDRESS 2-a <br />'--C-57 WELL DRILLING <br />PERFORATION CONTRACT— <br />PUBLIC WATER SYSTEM [] Yes [j No <br />1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />53-7687 FCR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />L Ziff c t,/ CITYZP ,VAn �,�''4 X3337 <br />N %� =/ ' 6- / PARCEL SIZ.E�LAND USE APPLICATION # <br />l nC• PHONE 7f9 7 ?'C-0 _ 'i — fl -1— <br />CrrY/STATE21P�jecifre,�/CA <br />PHONE�� 9- 7GS- (0(72 <br />CITY/STATE/ZZ d& /,V C I` C,4 9.r � <br />LICENSE NUMBER 5/,79/2 2 / EXPIRATION DATE_ <br />PERFORATION CONTRACTOR ADDRESS <br />!a' C-57 Well Drilling <br />Bureau of Aicohol, Tobacco and Firearms - Users of High Explosives <br />CHP Hazardous Material Transportation for Explosives <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />California Occupational Safety Health Blaster <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well <br />Detected / Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property <br />License Number t/ 3±/? / <br />plration Date J�'YJ-.20 <br />License Number24A=4/J �•4et <br />E it 70"Date/?•/-20 <br />License Number / *37&17 <br />License Number 340/ <br />Expiration Dates7 - �Q <br />Expiration <br />License Number _/ )y/6 <br />Date��- a -2G <br />Expiration Date 7. 2? -11 <br />❑ Caved In ❑ Pit Well nactive <br />❑ Test Hole <br />EXISTING WELL CONSTRUCTION DETAILS Cl Open Bottom <br />Well Log copy attached El Yes ❑ No Grout Seal ❑ No 11 Gravel Pack 13 Uncasetl ❑ O[Dia <br />❑ ,No ❑ Yes ft below ground surface (bgs) Hole Diameter <br />Well Conductor Casing ❑ Yes <br />Depth of Conductor Casing ft s inches <br />Well Casing Diameter L� �rf b9 Diameter of Conductor Casing inches <br />-� Total Depth Depth Depth to Water�/�ft <br />Depth of Casing ft bgs <br />DESTRUCTIONS CiFi ATION11 <br />Sealing Material from ft bgs to —./ 0 ft bgs Filler Material Coq C r {� <br />Well Casing to be Perforated by one of the followina methods: from G s ft bgs to /&> ft bgs <br />❑ Mills Knifefrom If bgs to ft bgs <br />Number of ruts every ft and / or <br />Oe Explosives 'Detonating cord ❑ 2705 <br />with projectiles every ft ❑ without projectile B/�,� �AQ <br />t/0' n DetQnati{ig cord and booste ❑ with projectiles every ft `- <br />e -AK C�tA7�d L.c� �,s ❑ w'outprojectile <br />�f eA,9av rbP �o �IPA�%1 <br />Sealing Material Neat Cement (94 lb ag / 5-6 gal water) Sand Cement <br />.1 <br />Bentonite (20% solids L�_sack mix / 7 gal water Bentonite Pellets <br />ManufacturerSpec%solids_ % Name <br />Placement Method PumpedFree Fall Other Specs on File Specs Submitted <br />Seal Completion Complete with Mushroom Cap S a <br />.� bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT <br />WORKERS COMPENSATIIN LAWS. I AM IN COMPLIANCE WITH ALL; <br />CE NOTICE REQUIRED FOR INSP <br />Application Accepted By <br />Destruction Inspection B, <br />EHD 43-08 <br />'l. <br />i� <br />7 <br />v° <br />iYMEN 1 <br />CEIVED <br />2 2U40 <br />iwHcdUIN COUNTY <br />IVIRONMENTAL <br />TH DEPARTMENT <br />