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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JoAouiN COuNTY ENVIRONMENTAL HEALTH DEPARTMENT 1863 Eat Hazelton Avenue -STOCKTON CA 95205 - (209) 468-3420 <br />nwr r 1end%ocy7d07 Cno luaoce nue F:YPIRFR 1 VI: Aa 1=RnM DATE ISSUED <br />JOB ADDRESS <br />Cm•� <br />CROSS STREET APN <br />PARCEL StzEAND USE APPLICATION fF <br />OWNER- <br />PHONEUQ. gl�gtZ <br />0w H EMR ApOp <br />�$/tIrtjo� <br />ciTY/sTATFJZIP 1 T' 1!L 4t4 col <br />CONTRACTOR m -III iN _ t,*- <br />PHONE LL <br />CONTRACTOR ADDRESS110iCRY/STATE;rbP. <br />A 7: <br />X- C-57 WELL DRILLING LICENSE Nu eER <br />E)(PmATION DATE J <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADD Rlaa <br />CrrY/STATEZP <br />❑ C-57 Wap Drilling <br />License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Uses of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Dale <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Data <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected/Suspected Well Water ontaminant(s) <br />Adjacent property with contamination (Address) <br />Known SoIUW&ter contaminants at adjacent property <br />E=Toa WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Unrated ❑ Other <br />Well Log copy attached ❑ Yea ❑ No Grout Seal ❑ No ❑ Yes <br />_ it below ground surface (bgs) Hole Diameter inches <br />Well Conductor Cuing ❑ es ❑ No Depth of Co ctor Casing itt�qs Diameter of Conductor Casing Inches <br />Well Casing Dlametat - inches Total Depth It Depth to <br />Water �it Depth of Casing It bgs. <br />DESTRUCTION SPECIFICATION <br />Sealing Material from _fl bps to ft bgs Filler Material <br />- <br />from It bgs to ft bgs <br />Well casing to be Derforsted by one of the following methods: <br />from ft bgs to it bgs <br />❑ Mills Knife Number of cuts every it and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />R ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />it ❑ without projectile <br />❑ Other <br />kelingMaterial n Nest Cement (94 *beg15-6ga1 water) n Sand Cement <br />sack mix7 gal water n Bentonite Pellets <br />Bentonite (20%` so1 Ids) U Manufacturer Spec % solids_% Name <br />❑ Specs on File U Specs Submitted <br />Placement Mem Pumped n Free Fall -I <br />Other <br />Seel Completion plate with Mushroom Cap it bgs u Complete to Existing Surface Pad <br />ik <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH ;SAN <br />JOAOUIN 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 I AM IN COMPLIANCE WITH Af-L <br />WORKERS COMPENSATION LAWS. <br />[MUM HOUFkIDVANCE NOTICE REQUIRED FOR III NgP1n'E'CTInONS <br />CONTRACTORS SIGNATURE <br />.A„ EPiRTMENT USE <br />Application Accepted By—� c{11�/I/1��- �l Date Area !� <br />Destruction Inspection By Date Employee I <br />COMMENTS <br />Date <br />EHD 43-06 <br />Invoice # I Well IDI <br />WELL DESTRUCTION PERMIT <br />vr4C. <br />TMFNT <br />