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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM 0 Yes ❑ No <br />SAH JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL ZUV 553-/b9/ 11 -OK INSPEGIIONS <br />rJ l-IMMO T 1r_A1c rKvm IJAIr ra�ueu <br />Joe ADDRESS (, CITY0P <br />N. <br />CROSS STREET APN PARCEL�SIZE <br />D USE APPLICATION <br />�p• <br />OWNER al/ PHONE <br />`(L�.tu <br />WU1t <br />OwmER ADDRESS(AN,11 CRY/STATEMPI1Y <br />w`2I • g4:14 ! <br />I PHONE G21 <br />- 2 <br />CONTRACTOR <br />1 <br />CO�NJT!RACTOR ADDRESS liq ANVywKIMcrrY/sTATE/TJP <br />G QM. -I <br />C-57 WELL DRILLING LICENSE NUMBER U ZJ,:n EXPItwTION DATE <br />30. 1107.27 <br />PER ORATION CONTRACTOR PRONE <br />PERFORATION CONTRACTOR ADDREss CRY/STATEIZIP <br />❑ C57 Well Drilling License Number <br />Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number <br />Expiration Date <br />❑ CHP Hamdous Material Transportation for Explosives License Number <br />Expiration Date <br />❑ San Joaquin County Sheriff-Ck oner Explosives Application and Permit License Number <br />Expiration Date <br />❑ California Occupational Safety Health - Bier License Number <br />Expiration Date <br />REASON FOtt DesTRucTioN ❑ Dry ❑ Replacement well ❑ Caved In ❑ PR Well <br />Inactive ❑ T C�/ <br />Detectexi/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />PA n _ <br />Known SoiVWater contaminants at adjacent property <br />Exis M WILL CONSTRtiC110N DETAB,S (3Open Bottom Gravel Pads ❑ <br />Uncased ❑ Other Eq h'O C <br />Well Log copy attached ❑ Yes �k No Grout Seal ❑ No Yes it below ground surface (bgs) Hole Diameter E° <br />Well Conductor Casing ❑ Yes *No Depth of Con or Casing ft Diameter <br />of Conductor Casing inches" <br />Well Casing Dtaarotnr �_ inches Total Depth ft Depth to Water�_ft Depth of Casing It bgs <br />DESTRUCT1oIt SPECFICALoff <br />Sealing Material from U—ft bgs to bgs Filler Material <br />from ft bgs to ft bgs <br />Well casing to be perforAW by one of the followI ig method$: from <br />ft bgs to it bgs <br />❑ MIOs Knife Number of arts every It and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles everyIt <br />❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles everyit <br />❑ without projectile <br />❑ 0@ier <br />Sealing Material Neat Cement (94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite <br />Pelle <br />Bentonite (20% solids) •_ Manufacturer Spec % solids _% Name <br />Specs on File Specs Submitted <br />Placement Method LI Pumped a Free Fat = Other <br />1 <br />Seal CompletionComplate with Mushroom Cap it bgs r Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS. CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONLY <br />Application Accepted By '/— Date d Area <br />Destruction inspection By Com+ "` 7/? Date 1 -Z2- Employee ID# A <br />COMMENTS <br />I7J <br />i P• <br />PE SC 1 Received <br />Codes Info <br />Checkill <br />Cash <br />Amount <br />Remitted <br />Dane Pefmitl <br />Service R # <br />invoice ti Well tD <br />y3173 <br />EHD 43-05 ( /' L/ / 647 <br />/ /�, WELL DESTRUCTION PERMIT <br />11123/21 `7 (p 4 / <br />