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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑Yes ❑No <br /> SAN JOAam COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDREss q CtTY/LP � 0 M <br /> CROSS STREET APN 221` 25D- 310 PARCEL S2E2--kLAND USE APPLICATION# <br /> OWNER PHONE u� <br /> m <br /> OWNER ADDRESS RIO* CffY/STATE2j�I(PJ <br /> CONTRACTOR 1 yy 'rd PHONE 210f <br /> • �/`CAJ ' /j �-^� <br /> CONTRACTOR ADDRESS 1 CrTY/STATEMIR M ,l A "I Si / <br /> C•67 WELL DRILLING LICENSE NUMBER EXPIRATION DATE• ;J I/ . <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safety Health-Blaster License Number Expiration Date <br /> REAsoN FoR DESTRUCTION Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br /> Detected/Suspected Well W Contaminant(*) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> E=TM WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pads ❑ Uncased ❑ Ottrer <br /> Well Log copy attached ❑ YesNo Grout Seal 11No ❑ Yes ft below ground surface(bgs) Hole Diameter Inches <br /> Well Conductor Casing ❑ Yes I No Depth of Conductor Casing It ba& Diameter of Conductor Casing inches <br /> Well Casing Diameter_lo inches Total Depth_ r—ft Depth to Water C' It Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from ft bgs to q0 ft bgs Filler Material from It bgs to ft bgs <br /> Well casing to beerg by one of the following methods: from ft bgs to ft bgs; <br /> ❑ Mills Kntfe Number of arts every ft and/or <br /> ❑ Explosives ❑ Detonating Cord ❑ wtth projectiles every_ ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ OtIm <br /> PellIn9 Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mar/T gal water Bentantte <br /> Bentonite(20 Ids) Manufacturer Spec%solids % Name i Specs on File Specs Submitted <br /> Placement MethodPumped Ci Free Fall r Other <br /> Seal Completion -1mplete with Mushroom Cap ft bgs i 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 '��3 5�i7�a Area S C <br /> Destruction Inspection By \ Date I-A.)�� Employee ICA <br /> COMMENTS r%.f <br /> 4 It <br /> PE SC Received CheclQW Amount PermlU <br /> Codes Info B Cash Remitted �Date i V � Invoice# TMF�eII IDN <br /> I Ts <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 11!23121 J Ilii V <br />