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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑9 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209) 468.3420 NON-RFFUNDARLF PERMIT CALL 12091 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 26901 N. Nowell Rd CITY21P Thornton/95686 CROSS STREET N . New Hope Rd APN 001-230-27 PARCEL SIZE 7 - ` nr-9��ND USE APPLICATION # OWNER PG&E PHONE OWNERADDRESS 6121 Bollinger Canyon Rd CITYISTATE/ZIP San Ramon, CA 94583 CONTRACTOR Cascade Drilling PHONE 916-638-1169 CONTRACTOR ADDRESS 3000 Duluth St CmvISTATE/ZIP West Sacramento, CA 95691 ■ C-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 p Test Hole Detected/ Suspected Well Water Contaminants) 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 N Other Sand Pack Well Log copy attached IN Yes ❑ No Grout Seal ❑ No N Yes 0-21 ft below ground surface (bgs) Hole Diameter 8 inches Well Conductor Casing ❑ Yes L No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 2 inches Total Depth 31 . 5 ft Depth to Water ft Depth of Casing 31 . 5 ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 It bgs to 31 . 5 ft bgs Filler Material N/A from It 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 everyft and/ or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile pJ other hollow stem augers Sealing Material ■ Neat Cement (94 lb bag / 5-6 gal water) ❑ Sand Cement sack mix 17 gal water C Bentonite Pellets ❑ Bentonite (20% solids) C Manufacturer Spec % solids _% Name :1 Specs on File ❑ Specs Submitted Placement Method ■ Pumped ❑ Free Fall ❑ Other Seal Completion ❑ 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE 4{ TITLE V.P. Operations DATE 7/212018 *OL P.A TMENT USE ON Application Accepted By Date Area Destruction Inspection By ' Date �^ Employee ID# CO MENTS c L� (i1S/Y i PE SC Received Check#/ Amount Peit/ _ _ _ _ _ ... Date _ _rm... Invoice is Well D# EHD 43-08�// WELL DESTRUCTION PERMIT revised 4/14/18 Q 107 r ('� 3/ _y 0 A a t x �;7 �414� I 2018 QUID FA,gR � IJIVj?' FNT t--- J — — 1._.1 ._._...._....L... ... I (�} HT, *OL P.A TMENT USE ON Application Accepted By Date Area Destruction Inspection By ' Date �^ Employee ID# CO MENTS c L� (i1S/Y i PE SC Received Check#/ Amount Peit/ _ _ _ _ _ ... Date _ _rm... Invoice is Well D# EHD 43-08�// WELL DESTRUCTION PERMIT revised 4/14/18 Q 107 r ('� 3/ _y 0 A a t x �;7 �414� I 2018 QUID FA,gR � IJIVj?' FNT