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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes M 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 JOB ADDRESS 2 - - CITY/LP Thornton/95686 CROSS STREET N. Nowell Rd pPIN 001-180-24 PARCEL SIZE57_36 LAND USE APPLICATION # OWNER PG&E PHONE OWNERADDRESs 6121 Bollinger Canyon Rd CITY/STATE/ZiP San Ramon, CA 94583 CONTRACTOR Cascade Drilling PHONE 916-638-1169 CONTRACTOR ADDRESS 3000 Duluth St CITYISTATE/ZIP West Sacramento, CA 95691 MC -57 WELL DRILLING LICENSE NUMBER 938110 EXPIRATION DATE 9 / 3 0 / 2 019 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/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) N/A Adjacent property with contamination(Address) N/A Known Soil/ Water contaminants at adjacent property N/A EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ■ Other Sand Pack Well Log copy attached ■ Yes ❑ No Grout Seal ❑ No M Yes 0-21 It below ground surface (bgs) Hole Diameter 8 inches Well Conductor Casing ❑ Yes LI No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 2 inches Total Depth 31 . 5 It Depth to Water ft Depth of Casing 31 • 5 ft bgs DESTRCCTIO\'SPECIFICATION Sealing Material from 0 ft bgs to 31 . 5 ft bgs Filler Material N/A from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from 0 ft bgs to 31 . 5 ft bgs ❑ Mills Knife Number of cuts every ft and / or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ■ pl�fhollow stem augers Sealing Material • Neat Cement (94 lb bag/5-6 gal water) ❑ Sand Cement sack mix / 7 gal water C Bentonite Pellets ❑ Bentonite 120% solids) 7 Manufacturer Spec % solids_ % Name 7 Specs on File 7 Specs Submitted Placement Method 9 Pumped ❑ Free Fall ❑ Other Seal Completion r Complete with Mushroom Cap ft bgs ■ Complete to Existing Surface Pad I HEREBY CERTIFY THAT I 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. MINIMUM yy/4�88 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 7/23/2018 1 p CONTRACTORS SIGNATURE OA99" TITLE V.P. Operations DATE / /23/2018 Application Accepted By _ Destruction Inspection By PE SC Received Check#/ Amount Date Pertnitl Invoice # Well ID# Codes Ifo as emitted Sc a st #_ 11 k-277-1 I — / ///7' 1 1h -�7�1-11111 1 I t 11,%1:1 EHD 43-086 # FIV / � 43 3/ WELL DESTRUCTION PERMIT revised 4/14/18 ' N