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WELL DESTRUCTION PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT CALL <br />JOB ADDRESS Q-'> I� ,1`-t <br />CROSS STREET !�t/V t. o <br />OWNER U VUj G� -" <br />P. OWNER ADDRESS ice• o - <br />CONTRAC <br />t - <br />PUBLIC WATER SYSTEM ❑ YesXNO <br />1868 East Hazelton Avenue - STOCKTON CA 95205 - (209)J)46``8-3420 <br />7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />I CITY/ZIP J,!�- CYC <br />PARCEL SIZEL_LLAND USE APPLICATION # <br />—PHONE <br />_CITY/STATE/ZIP I2 - <br />CONTRACTOR ADDRESS OD I )CITY/STATE/ZIP <br />I[J�. C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />C-57 Well Drilling <br />Bureau of Alcohol, 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 />CITY/STATE/ZIP <br />License Number "t� <br />License Number <br />License Number <br />License Number <br />License Number <br />Expiration Date Cl <br />Expiration Date _ <br />Expiration Date _ <br />Expiration Date <br />Expiration Date _ <br />REASON FOR DESTRUCTION Vory ❑ Replacement Well El Caved In El Pit Well Inactive El Test Hole <br />Detected/Suspected Well Watrr/Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property _ <br />EXISTING WELL CONSTRUCTION DETAILS/ ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes t No Grout Seal ❑ No ❑ Yes It below ground surface (bgs) Hole Diameter <br />Well Conductor Casing ❑ Yes No Depth of Conductor Casing If bgs Diameter of Conductor Casing <br />Well Casing Diameter___ inches Total Depth _._ It Depth to Water -Umqbhm Depth of Casing _ <br />DESTRUCTION SPECIFICATION <br />Sealing Material from _ T ) ft bgs to ft bgs Filler Material__ from ft bgs to s <br />Well casing to be perforated by one of the following methods: _ from _ ft bgs to ft bgs <br />❑ Mills Knife ___ Number of cuts every _ __ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted <br />acement Method x Pumped Fr e Fal l Other <br />Seal Completion Complete with Mushroom Cap_ ft bgs l 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 SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 ALL <br />WORKERS COMPENSATION LAWS. <br />I <br />MI I 'H R ADVA IlCE,REQUIRED FOR INSPECTIONS 2 <br />CONTRACTORS SIGNATURE TITLE DATE ✓ �� ` <br />P A R T M E N T <br />Application Accepted By <br />Destruction Inspection By <br />COMMENTS <br />U.!11AL <br />.!�►� i �1 <br />W4 ! I ?I !M:.1 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check <br />ash <br />Amount <br />Rer itt d <br />Permit/ <br />Date Service Request # <br />Invoice # <br />Well ID# <br />6 <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />4/30/12 <br />