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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM [-]Yes SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(2209)468-3420 NON-REFUNDABLE PERMIT CALL 209 9` 7697 FOR INSPECTIC EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS192.1 e tkv CITYILP� 01535"1 a CROSS STREET • PN PARCEL SIZE1" D USE APPLICATION# OWNER PHONE mayc`-44 /25 - -I'raC-V OWNER ADDRESS dh ` CRYISTATEIZIP� CONTRACTOR HONE I CONTRACTOR ADDRESS I q Cm/STATFJZIP A 9 IE C-57 WELL DRILLING LICENSE NUMBER •2 {OOQ 15 ExPRAnoN DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP IY 057 Well Drilling License Number 2_9p X11 . 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 ❑ 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 Exismo WELL CoNsTgucnoN DETA&§ ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes X No Grout Seal ❑ Nn ❑ Yes ft below ground surface(bgs) Hole Dlameter Inches Well Conductor Casing❑ Yes ❑ No Depth of Conduct r Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth it Depth to Water it Depth of Casing It bgs DESTRUCTION SPEC'IFR'ATION Sealing Material from () ft bgs tolj5Cbgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the followinst methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets xBentonite(20%solids)-, olids facturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fail Other Seal Completion Comple shroom 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. 1 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 -IRF- CONTRACTORS IRF CONTRACTORS SIGNATURE - ITLE DATE I qC�jENT ElVPn 2021 IV Qu(N co NMENT�NIy - - - - - - - - - - �PARTti ENT DEPARTMENT USE ON Application Accepted By � `/ Date 7 Area Destruction Inspection By 1Date Employee ID# COMMENTS=BYt'!ln itDr St[i l Y�l �Fb� PrMst, PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By__ Remitted Ice Re u t EHD 43-08 WELL DESTRUCTION PERMIT 1015107