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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes C4 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT ;ALL 209 953-7697 FOR: •,IuNJ EXPIRES'I YEAR FROM DATE ISSUED JOBADDRESS 1207 E. Grant Line Rd. clrymP Tracy 95304 CROSSSTREET E. of MacArthur Dr. APN 213-070-22 PARCEL SIZE R,,Z4.AND USE APPLICATION# OWNER IPT Tracy DC IV LLC PHONE 949-892-4911 OWNER ADDRESS 4675 MacArthur Court, Suite 625,� CITYISTATEIZIP Newport Beach, CA 92660 Is CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2020 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 Well Drilling License Number 290813 Expiration Dale 5-31-20 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 [X Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes No Grout Seal ❑ Vo ❑ Yes____ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes �!Q No Depth of Conductor Casing ft bgs Diameter of Conductor Casing ___inches Well Casing Diameter 8" PVC inches Total Depth 150'+ft Depth to Water _ _ft Depth of Casing DF.STRUMON SPECIFICATION Sealing Material from _0 ft bgs to JaQ'+ _ft bgs Filter Material__ _ from_ ft bgs to _ _ft bps Well casing to be perforated by one of the following methods: __. -from _It bgs to_ it bgs ❑ Mills Knife Number of cuts every k and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every_ _ it ❑ without projectile ❑ Other Sealing Material Neat Cement(94/b bag/5-6 gal wafer) Sand Cement sack mix/7 gal water Bentonite Pellets X Bentonite(20%solids) Manufacturer Spec%solids_% Name Bariod Quik Grout Specs on File Specs Submitted Placement Method x Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 4 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. ?FONIR,K., . R jNgnr_-r71 �rC CONTRACTORS SIGNATURE E V.P. DATE Aug. 6, 2018 JpS SEE ATTACHED !® GCV OPcl: MENS �N� AP A M E N T U S E O N L �j Application Accepted By Date Area Destruction Inspection By Date loyee ID# COMMENTS PE SC Receiv Amount Date PemtlU Invoice# Well ID# odes Info B Cash R i Service Request# EHD 43-08 WELL DESTRUCTION PERMIT 1015107