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WELL DESTRUCTION PERMIT l APN 223-200-13 PUBLIC WATER SYSTEM ❑Yes (X No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 432 N. Fremont St. cirYlziP Manteca 95336 CROSS STREET S. Of Alameda St. A N - - PARCELSZE.15LAND USE APPLICATION# 0 OWNER Richard and Linda Aksland�2r,� D>h Ci,lcyllr'/ I IE -�55'-`6"272-Jeff Aksland OWNER ADDRESS 105 E. Yosemite Ave. /�/ iJ -1, y�ra�"t-CITY/STATE/ZIP Manteca, CA q5336 y CONTRACTOR Hennings Bros- DrllhngCo. Inc- PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 1 add Rd- CITY/STATE/ZIP Modesto CA95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2018 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATEIZJP (y( C-57 Well Drilling License Number 290813 Expiration Date 5/31/18 Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Dale 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 Qj 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 IN Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes Q( 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 2"-3°_inches Total Depth eSL40_It Depth to Water- _ -_ ft Depth of Casing DESTRUC'i]ON SPECIFICATION Sealing Material from 0 ft bgs to 40 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 It bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every _It ❑ Without projectile ❑ Detonating cord and boosters ❑ with projectiles every _It ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name HOIe PIl lgCfi p Specs on File Specs Submitted Placement Method Pumped XFree Fall Other Seal Completion Complete with Mushroom Cap 4 It bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS- I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. `y1}MINIMUM 24 HO•{U�R•ADVANCE NOTICE RE UIRED FOR INSPECTIONS CONTRACTORS SIGNATURE 11 Y, .r�a� TITLE Vice President DATE NnV- 21, 2017 ---T-1 - - - -- - - - - fi -- - - -- - � be A-Bandon CIA ILL,^ TT PARTMENT USE ONLY D Application Accepted By Date IJ "�4 Area Destruction Inspection By Employee ID# � , .e ) �A �1 PE Sc Received Amount PeFmi Pate Invoice# Well ID# S Codes Info Cash Remitted Servilir ce Re uest# EHD 43-08 WELL DESTRUCTION PERMIT 10/5(07