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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes ® No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-RFFUNDARI F PFRMIT CALL /2091 953-7697 FOR INRPFCTIONS EXPIRES 1 YFAR FROM DATF ISSLIFO <br />JOSADDRESS "nn I7 Tt d <br />CITYIZIP Thornton/95686 <br />CROSS STREET N . Nowell Rd APN 002-230-45 <br />PARCEL SIZE b2 8 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 DriliinCj <br />PHONE 916-638-1169 <br />CONTRACTOR ADDRESS 3000 Duluth St <br />CITYISTATE/ZIP West Sacramento, CA 95691 <br />■ C-57 WELL DRILLING LICENSE NUMBER 938110 <br />EXPIRATION DATE 9/3C/2019 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITYISTATEIZIP <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 Date <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 p Test Hole <br />Detected/ Suspected Well Water Contaminants) 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 C Other Sand Pack <br />Well Log copy attached 0 Yes ❑ No Grout Seal ❑ No E Yes 0-21 ft below ground surface (bgs) Hole Diameter 8 inches <br />Well Conductor Casing ❑ Yes N No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 2 inches Total Depth 31 . 5 ft Depth to Water ft Depth of Casing 31 . 5 ft 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 />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />pybthollcw stem augers <br />Sealing Material ■ Neat Cement (94 Ib bag 15-6 gal water) Sand Cement Sack mix / 7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids_ % Name <br />Specs on File Specs Submitted <br />Placement Method • Pumped Free Fall <br />Other <br />Seal Completion Complete with Mushroom Cap ft bgs <br />■ 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 <br />�48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE � " TITLE V.P. Operations DATE 7/23/2018 <br />H <br />Application Accepted By <br />Destruction Inspection <br />COMMENTS <br />PE SC ReceivedCheck#/ Amount Date Permit/ Invoice # Well 1D# <br />Codes Info ash emitted i e <br />EHD 43-08 / "�(�/7� �J/ WELL DESTRUCTION PERMIT <br />revised 4/14/18 <br />