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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 />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 26180 N. Nowell Rd <br />CITY/ZJP Thornton/95686 <br />CROSSSTREETN• New Hope Rd APN 001-230-21 <br />PARCEL SIZE 23.3 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 9/30/2019 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CIN/STATE/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 -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive M 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 ! Other Sand Pack <br />Well Log copy attached 0 Yes ❑ No Grout Seal ❑ No i Yes o-21 <br />it below ground surface (bgs) Hole Diameter 8 inches <br />Well Conductor Casing ❑ Yes III 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 It Depth of Casing 31.5 ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to 31 . 5 it bgs Filler Material N/A from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />from 0 it bgs to 31 . 5 ft bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ Without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />It ❑ without projectile <br />■ p� hollow stem augers <br />Sealing Material a Neat Cement (94 Ib bag 15-6 gal water) n Sand Cement sack mix / 7 gal water E Bentonite Pellets <br />Bentonite (20% solids) 7 Manufacturer Spec % solids_ k Name <br />7 Specs on File 7 Specs Submitted <br />Placement Method • Pumped ❑ Free Fall ❑ <br />Other <br />Seal Completion n 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 TITLE V.P. Operations DATE 7/23/2018 <br />i <br />AIR ENT USE ONL <br />Application Accepted By Date �e Area _ <br />Destruction Inspection By A / Date Emplo ee ID# <br />COMMENTS �% C - <br />Eyv <br />PE SC I Received Check#I Arnount Permit/ <br />..,-- Data e______, ,, Invoice # Well ID# <br />EHD 43-08 <br />revised 4/14/18 LXl/ y/D/lOb / <br />WELL DESTRUCTION PERMIT <br />tyyf <br />b <br />