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kic 44bir/441/' S6D ;4) 44 Q Itt•Q 4 / Vi4944 *41, ~ez, lc9r7 2)/3/Pd j 6 /6-``,1% 7U4 48 ADVANCE NOTICE REQUIRED FOR INSPECTIONS TITLE DATE WELL DESTRUCTION PERMIT PUBUC WATER SYSTEM Yes E No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT NON-REFUNDABLE PERMIT 1868 East HazeIton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ii /S-C) /t /r i>41,--9/27-1-) /2A? CITY/ZIP 77Z 11'- CROSS STREET e.c.wier.9-4..._ AlreyeAt/ApN 6,2144--dy-o/ PARCEL SIZE/34 LAND USE APPLICATION # OWNER daLl#:::' Z-14- Z .2.1-e_ ,-) F.-2g 10: 'f-- 419/01-4 PHONE 576 —7/9 — O2--X _ OWNER ADDRESS %TO /77Atac i Air- /572't '''.-1-- ./W1"-i4'(stT. TY/STATE/ZIP .../1--.1,,,ieK'-,e; .----.' /a177 CONTRACTOR 1 7" 1- 9- 1 0 9 - 7 .r:?°.-7. _ -y1:., . - " • 77;r• - --- PHONE 95/ CONTRACTOR ADDRESS 2/20 114z—C-OX /24C) CITY/STATE/ZIP 5 -*1-,/6---"14- ‘--•'.--...." C-57 WELL DRILLING LICENSE NUMBER *Xarl.:, EXPIRATION DATE , PERFORATION CONTRACTOR M C- Irl'Ilc.h Wel/ Peff PHONE Z4 .- 76/ - 5-2' Z y PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 0 C-57 Well Drilling License Number -,Exiration Date Ai A Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Cat- W 4); '33-qt C4 xpiration Date ;Nil CHP Hazardous Material Transportation for Explosives License Number Dt*s nor hilrisp%i- Expiration Date fl r San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number d 1 -00 Expiration Date LI /120/d3 California Occupational Safety Health - Blaster License Number gaol Expiration Date REASON FOR DESTRUCTION 0 Dry 0 Replacement Well 0 Caved In 0 Pit Well [2f Inactive 0 Test Hole Detected / Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS 1?.) Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached 0 Yes 0 No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter /6 inches Total Depth ft Depth to Water 4..S.7-- ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION -rvc•---- p°,1-441.3,1r17- ...d. Sealing Material from -----s „-A) ft bgs to ft bgs Filler Materia l' from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs 0 Mills Knife Number of cuts every ft and / or Explosives2W Detonating cord 0 with projectiles every ft 0 without projectile /CV 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile 0 Other Sealing Material Neat Cement (94/b bag / 5-6 gal water) Sand Cement /0 - sack mix I 7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other -r -WP --- Seal Completion Complete with Mushroom Cap j 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. :SSMIUU V 3-LIS CONTRACTORS SIGNATURE DEPARTMENT USE ONLY Application Accepted By Destruction Inspection By A COMMENTS 1-1,1311 /11 he) e-t f ?a, rr) Oil() C?0(-) ra°21,-) ic 1es rep. t The eri-he oiei I I. be 3 Date Date Slrft;PC/ Employee ID# dPef 'Pr 416 ri 300 -reel.. Area PE Codes SC Info Received By h(.1.) ..c ash Remitted Amount Date Permit/ Service Request # Invoice # Well ID# '13711 ic-`-;-- aig_ /6030 #3as- ot-1-21 vvooqz5oi EHD 43-08 revised 4/14/18 WELL DESTRUCTION PERMIT