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WELL DESTRUCTION PERMIT I tg PUBLIC WATER SYSTEM ❑ Yes Lb No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 4168-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED • JOB ADDRESS 1 �C �1 e' `l \�ti` �� )L /�n' CITYIZIP W 4 r � C1` C1 5RS 9 CROSS STREET'�nf �s�«l,"AC'1 i-0 1Zv APN G 1 3 �. PARCEL SIZE._ OWNER Le C r &j 1 C tt* A UAAItFC' J _ ��PHONE 2C' USE APPLICATION # (/ r�7- A5c�3 OWNER ADDRESS�11\lel W G`G �� `�C e I� 17' CITY/STATE21P �U`�C}�, ay C I C A G5 sg CONTRACTOR ,(-,,, \ y t n tl^ PHONE 36g - R 7 7 g 2 CONTRACTOR ADDRESS P. O • o x "T � (j CITY/STATE/ZIP Lt 1 � C A\� % 7 �. C-57 WELL DRILLING LICENSE NUMBER 7 -1(7 -1 3 Q O EXPIRATION DATE Ja PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP Received By ❑ C-57 Well Drilling License Number 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 F® ►�' Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes `i` No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conducttor,C�,as�in/y _ ft bb�gs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth �� ' Depth to Water,u F () . - It Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material fromft bgs to �_ It bgs Filler Material_ from ft bgs to ft bgs Well casing to be perforated by one of the following methods: _.____ from ft bgs to It 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) Bentonite (20% solids) 1 Manufacturer Spec % solids_ Placement Method Pumped i i Free Fall Seal Completion Complete with Mushroom Cap Sand Cement Name Other mix17 gal water k Bentonite Pellets I Specs on File i Specs Submitted It 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. UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS Application Accepted By _ Destruction Inspection By COMMENTS PE Codes SC Info Received By Check#/ Cash Amount Remitted Date Permit/e Service Re uest # I ID# EHD 43-08 WELL DESTRUCTION PERMIT 4/30/12 r� Y v 0