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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes [I 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 CITY/ZIP Thornton/95686 CROSS STREET N . Thornton Rd APN 01'1-120-21 PARCEL SIZE 4 3. 5 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 CITY/STATEIZIP West Sacramento, CA 95691 ■ C-57 WELL DRILLING LICENSE NUMBER 938110 EXPIRATION DATE 9 / 3 0 / 2 019 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/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 Dale California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive N 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 X Yes ❑ No Grout Seal ❑ No A Yes 0-21 It below ground surface (bgs) Hole Diameter 8 inches Well Conductor Casing ❑ Yes AN 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 DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to 31 . 5 flogs 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 a p hollow stem augers Sealing Material ■ Neat Cement (94 Ib bag 15-6 gal water) Sand Cement Sack mix 17 gal water Bentonite Pellets Bentonite (20% solids) I Manufacturer Spec % solids _% Name -! Specs on File i 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 �Av TITLEV.P. OPerationS DATE 7/23/2018 Application Accepted By _ Destruction InS{(�ection By COMMENTS 1 J O S '(PA, MENT USE.�ON)Y ►" 1 � Date / �� ' 44'AfAii Area Employee ID# , PE I SG I Received I Check#/ I Amount I Date I _ . Pe"m" ... I Invoice # I Well ID# EHD 43-08 revised 4114/18 WELL DESTRUCTION PERMIT