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EMAILED r y - V7 �nl I I Dle s4 r u J-(o n PUBLIC WATER SYSTEM ❑Yes p No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED n. JOB ADDRESS 1 V Jyy��LCITYMP NON�N I ✓�J1L Wl y CROSS STREEtT fy, ' p ' 1 APNy- ..� -Z�✓ !PARCEL SIZE102- LAND USE APPLICATION# c OWNER 14IV1�L1� b I l '7 PHONE20- OWNER ADDRESS 1 ZO CITYISTATEIZIPN CONTRACTORUZIE PHONE } 2 .1124) CONTRACTOR ADDRESS + J Vp-.. PV(/ CITYISTATEMP MyGyVJ rill q(r-31�7 ' C-57 WELL DRILLING LICENSE NUMBER -%V 2a EXPIRATION DATE 0,4- -0 2-021� i PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom l Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter�Vl inches Total Depth .It Depth to Water ?ift Depth of Casing ft bgs DESTRUCTION SPECIFICATION I /)A Sealing Material from �_ft bgs to __ft bgs Filler Material from _ft bgs to Well casing to be perforated by one of the following methods: from ft bgs to ft bgs / Of ❑ Mills Knife Number of cuts every ft and/or _- _ A01? ❑ Explosives ❑ Detonating cord ❑ with projectiles every_ ft ❑ without projectile S, ,,TT , 13 Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile qN JO4 ❑ Other NEEN�IR QUIIV Sealing Material Neat Cement(94/b bag/5-6 gal water) Sand Cement sack mix/7 gal water FC PelletspgRN� TY Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitt Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap �l 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 / !/ f L Date � Z Area f 2(— Destruction Inspection By 1 – Date u ZZ Employee ID# COMMENTS C- PE PE SC Received Check#/ Amount Date PermiV Invoice# Well IDX Cor"-- Info BY Cash Remitted Service Re uest#