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t , c WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLEPERMITCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1�YEEAR FROM DATE ISSUED JOB ADDRESS 7,49 S tni�,KcK LN CITY/ZIP 31&C TC t" /JJ J5✓ CROSS STREET L- • 1`NAI NJ APN j J�� It u)-c- PARCEL SIZE , 3L LAND USE APPLICATION# b OWNER PHONE 11�� 1� p OWNER ADDRESS ,�5( VL L`--[ l raS (�i V t I C, CITY/STATE/ZIP RU5, Vi LL,1, C/-I CONTRACTORaEotr),yq JCRyILC�� ('QC- PHONE �Ik:1 3?-3 - .SL's CONTRACTOR ADDRESS FG 5�Y- 2`I �b5 j CR 'Y/STATE/ZIPS• &K-L, CA y -' 2---'C.57 ACC-57 WELL DRILLING LICENSE NUMBER C�l f, j EXPIRATIO N /DATE 1 3c, PERFORATION CONTRACTOR ;nn 1VVylA PHONE_ -74 PERFORATION CONTRACTOR ADDRESS �Ji^ } (�Y lf<'j l d 5,7D D �l y CITY/STATE/ZIP ❑ C-57 Well Drilling License Number ClAt Expiration Date lD Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number f %?GLS Expiration Date ,e CHP Hazardous Material Transportation for Explosives License Number I Expiration Date X San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date Er California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well 2-1-nactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS m Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes EY No Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes M-No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter c I inches Total Depth—1-7�ft Depth to Water_ ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: _from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or [ Explosives 0- Detonating cord ❑ with projectiles every ft Ea� without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material I Neat Cement(94 Ib bag/5-6 gal water) nd Cement /v sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) i i Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method ,tl- Pumped IFree Fall Other Seal Completion fk Complete with Mushroom Cap 5-� ft bgs - Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209)953-7697 FOR INSPECTIONS /DEPARTMENT USE ONLY Application Accepted By Date 2 ! Z Z 4- Area - / ` I ZL Destruction Inspection By Date Employee ID# AA COMMENTS 11 i=L{ ty -�l� AQ SA Ue 4)6 !T NM Atry PE SC Received Chec_W Amount Permit/ # WeT t Codes Info B Date ash Remitted Service Request# 3 t�� -5) >" 2.2.24 WF00459SI EHD 43-08 WELL DESTRUCTION PERMIT '1/23/21