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to <br />0144011:i1I1AIIs] ►M»:41711kI <br />PUBLIC WATER SYSTEM ❑ Yes ❑E No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-RFFImnAFII F PFRIUIT CAI I MOQt Qt;'1-7AQ7 FAR INSPFCTInNR FXPIRF.R 7 YEAR FRnlu nATF IssuFn <br />JOBADDRESS 26982 N. Nowell Rd <br />CITY17jP Thornton/95686 <br />CROSSSTREET N. New Hope Rd APN 001-230-02 <br />PARCEL SIZE 74. 5 LAND USE APPLICATION# <br />OWNER PG&E <br />PHONE <br />OWNERADDRESS 6121 Bollinger Canyon Rd <br />CITY/STATE/ZIP San Ramon, CA 94583 <br />CONTRACTOR Cascade Drilling <br />PHONE 916-638-1169 <br />CONTRACTOR ADDRESS 3000 Duluth St <br />CITY/STATE/ZIP West Sacramento, CA 95691 <br />■ C-57 WELL DRILLING LICENSE NUMBER 938110 <br />EXPIRATION DATE 9/30/2019 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Dale <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive O Test Hale <br />Detected / Suspected Well Water Contaminant(s) N/A <br />Adjacent property with contamination(Address) N/A <br />Known Soil /Water contaminants at adjacent property N/A <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased N Other Sand Pack <br />Well Lag copy attached fi Yes ❑ No Grout Seal ❑ No Cr Yes 0-21 <br />i ft below ground surface (bgs) Hole Diameter 8 inches <br />Well Conductor Casing ❑ Yes IN No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 2 inches Total Depth 3 1 . 5 ft Depth to Water ft Depth of Casing 31 . 5 It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to 31.5 ft bgs Filler Material N / A from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />from 0 ft bgs to 31 . 5 ft bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ With projectiles every <br />it ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />�i Otherhollow stem augers <br />Sealing Material ■ Neat Cement (94 lb bag 15-6 gal water) ❑ Sand Cement sack mix 17 gal water C Bentonite Pellets <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids _% Name <br />❑ Specs on File =i Specs Submitted <br />Placement Method ■ Pumped ❑ Free Fall ❑ <br />Other <br />Seal Completion ❑ Complete with Mushroom Cap ft bgs ■ Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE 11A, 0�— TITLE V.P. Operations DATE 7/23/2018 <br />It4! __ <br />SA <br />ILI <br />tl..... .. .,... I <br />EI - <br />G -- <br />i._ <br />Application Accepted By <br />Destruction Inspec�tion j!B' <br />COMMENTS <br />_y <br />Y <br />b <br />I I I I I Date I .,_= ' I Invoice# I Well D# I <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />revised 4114/18 <br />