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L <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS •-1G�4 14Ar V C � A Q D <br />CITY21P A cc%,-\ ro C+ 7 .22 <br />[� <br />CROSS STREET E �� I F rc r) APN 0 l •— C;. O--c,C <br />PARCEL SIZE •LAND USE APPLICATIONS <br />OWNER D c <ti A (C� A '' C K en <br />PHONE <br />OWNER ADDRESS 3-3 C) 9 1 ti C Alli C) 917. <br />1 <br />CITYiSTATEIZIP �QCam J^ c' C � � 1 � � --,)c,CONTRACTORS <br />`1 <br />j fl I I e y Ort„ 1 n r1 <br />PHONE <br />CONTRACTOR ADDRESS . C c l JAR <br />CITYISTATE21P 9 5 C S I\ <br />) <br />r C-67 WELL DRILLING LICENSE NUMBER ry �'� rl _� <br />EXPIRATION DATE 7- 9 7 I <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CM/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION A Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known .SoiI/Water contaminants at adjacent propeKy <br />EXISTING WELL CONSTRUCTION DETAILS �K Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes )) No Grout Seal A No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes It No Depth of Conductor Casing <br />It bgs Diameter of Conductor Casing inches <br />Well Casing Diameter inches Total Depth (1-10 ft Depth to Water (I Depth of CasingC_ C� ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from _ft bgs to x It bgs Filler Material <br />It,l) S COk from Cr ft bgs to r7 ft bgs <br />Well casing to be perforated by one of the following methods: <br />from It bgs to <br />❑ Mills Knife Number of cuts every ft and/or <br />� E <br />A <br />❑ Explosives ❑ Detonating cord El with projectiles every <br />ft ❑ without projectile CEI 1 <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile L <br />❑ aha <br />pe-�Q /� <br />Material ❑ Neat Cement (94 Ib bag/r6 gal water) IK Sand Cement le sack mixl7 gal water ❑ EILL I0 7 2 <br />PelletsSeealing <br />�E <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name <br />❑ Specs on Fileed <br />Placement Method Pumped ❑ Free Fall El( <br />Other cc <br />VrNM' EN1 <br />�. <br />Seal Completion � Complete with Mushroom Cap :� ft bgs 13Complete to Existing Surface ad EPq RT/ <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT <br />i <br />Application Accepted By L f�- <br />Destruction Inspection By �L✓�L =Six1 ��/- <br />COMMENTS Co:, f(.-' � 1� � yJ : � I I r g Gi►iC.� now !1P e <br />11 <br />1O �nGti cu':r�c E!,<rrVFd ^` �(DQ- 211�2E'2Z <br />USE ON Y <br />Date _ Area ('� <br />Date Z 1� 1 �. Employee ID* <br />vin. :..• k 71'1 iin i .. i 1-c a. I✓ i. Y -v 7 <br />IT <br />'ID <br />,VTY <br />NT <br />PE <br />Codes <br />Sc Received Check*! <br />Info AYL Cash <br />Amount Date PerrnIV Invoice * Well ID* <br />Remitted Service Reg uest * <br />373 <br />ii�,, iA''� <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />��FS5- a <br />