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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 />N(1N_RGCI WnAGI F PCDIUIT rel I ignai Q54_7AQ7 Fno INCDCr`TInNC FYPIRFS 1 YFAR FRnM I7ATF IfiCllFn <br />JOBADDRESs 6701 W Kile Rd <br />CITYIZIP Thornton/95686 <br />CROSS STREET N . Ray Rd APN 0 01-2 5 0 - 0 6 <br />PARCEL SIZE -58 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 / 3 0 / 2 019 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITYISTATE/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 Date <br />CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />-- San Joaquin County Sheriff-Ceroner Explosives Application and Permit <br />License Number Expiration Date <br />i California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive N Test Hole <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 9 Other Sand Pack <br />Well Log copy attached 0 Yes ❑ No Grout Seal ❑ No M Yes 0-21 It 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 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 followina methods: <br />from 0 ft bgs to 31 . 5 It bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />fl ❑ without projectile <br />❑ Detonating Cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />p�thollcw stem augers <br />Sealing Material ■ Neat Cement (94 Ib bag 15-6 gal water) 11 Sand Cement sack mix / 7 gal water Bentonite Pellets <br />: Bentonite (20% solids) 1 Manufacturer Spec % solids_ % Name <br />I Specs on File i Specs Submitted <br />Placement Method a Pumped Free Fall D <br />Other <br />Seal Completion Complete with Mushroom Cap It 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE TITLEV-p. Operations DATE 7/23/2018 <br />N )ek �M <br />Application Accepted By <br />Destruction Ins^ppe�ct on B <br />COMMENTS C/ �JQ <br />PE SC Received Check#I Amount Permit/ <br />ode Info Cash emitted Date rvice quest # Invoke # Well ID# <br />i <br />EHD 43-08 g/07,��.J 2 / WELL DESTRUCTION PERMIT <br />revised 4/14/18 s <br />