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EMAILED <br /> C-\M <br /> PUBLIC WATER SYSTEM ❑Yes U No <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)353-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I -CITYIZIPT�� <br /> CROSS STREET �/' 1APN Z �" PARCEL SIZE�//BLAND USE <br /> APPLICATION <br /> �/1/#, O <br /> OWNERAA /� /1 p I �}���I7�I. mob Uyl OT 11" •_ Si3OI'�, t "vy J+� <br /> OWNER ADDRESS � I V 1{�� �y� �l J I 1 -� CITYISTATE/ZIP <br /> 2- <br /> CONTRACTOR PHONE 2 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIPVO" %-2q J <br /> C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE V� � <br /> 2-Ci - <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 Water 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 ❑ No Grout Seal ❑ No ❑ Yes _ _ft below ground surface(bgs) Hole Diameter --Inches <br /> Well Conductor Casing El Yes ❑ No Depth of Cori+ or Casing ftxigS f Diameter of Conductor Casing Ingres <br /> Well Casing Diameter inches Total Depth ft Depth to Water_ V __ ft Depth of Casing_- ft[XJ5 <br /> �!'— - <br /> DESTRUCTION SPECIFICATIONI <br /> from ft bgs to <br /> Sealing Material from � _ft bgs to � ft bgs Filler Material _ _._- 9 -- ft bgs <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 everyft ❑ Without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ Without projectile <br /> ❑ Other— __ <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal wafer) Sand Cement sack mixR gal water Bentonite <br /> Pellets <br /> Bentonite(20° solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> idc <br /> Pement Method Pumped Free Fall f Other <br /> Seal Completion kmplete.with Mushroom Cap ft bgs Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> ,0� � DEPARTMENT USE O L _ <br /> Date C1 fi3 Area _ <br /> Application Accepted By T�. <br /> Destruction Inspection By Date Z Employee ID# IV <br /> 21* <br /> COMMENTS 11 I'f I f CFs,�F <br /> s �.S <br /> 23 <br /> PE SIC Received Amount Date Permitl- - Invoice# Well ID# <br /> R uest# T <br /> Codes Info B milted Service <br />