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WELL DESTRUCTION PERMIT 2 Well Abandonments PUBLIC WATER SYSTEM C]Yes Cf No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL'209)5:.- '97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED vn JOB ADDRE551124 Pescadero Ave. (1137 E. Grant Line Rd.) cITYmp Tracy 95304 CROSS STREET E. of MacArthur Dr. APN 213-070-81 PARCEL SIZE35.$9ND USE APPLICATION# C OWNER IPT Tragi DC IV LLC PHONE 949-892-4911 V, OWNER ADDRESS 4675 MacArthur Court, Suite 625 CITY/STATEIZIP Newport Beach, CA 92660 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITYISTATEiZJP Modesto. CA 95356 Ij C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31,2020 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP @4 C-57 Well Drilling License Number 290813 Expiration Date 5-31-20 Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Dale CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date Califomia Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well IX Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent propertywith contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes {Z{ No Grout Seal ❑ No ❑ Yes _ it below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes No Depth of Conductor Casing ft bgs Diameter of Conductor Casing_ inches Well Casing Diameter 8"Steelinches Total Depth est__50ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from _eft bgs to est. 5 'it bgs Filler Material _ _from ft bgs to ft bgs Well casing to be perforated by one of the following methods: _ from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ With projectiles every R ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix 17 gal water Bentonite Pellets XBentonite(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. 1 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 74 HOUR ADVANCE NOTICE REOU a n r R INSPECTIONS CONTRACTORS SIGNATUREIA.Qw&,;'��"-aut-46i S"ETIw r V.P. DATE Aug. 6,2018 PAYS NT SEE ATTACHED - e^ 0-i �[�► - AUG p 7 18 SAN JOggUlN _ NEgLmR, WEly Co NTY - - ENT ENT USE O � ^ Application Accepted By Date Area (SII Destruction Inspection By %�% Date 061Employee I COMMENTS 1 A ✓ r l 7( 4- C' 1r S PE SC Received Check#/ Amount Permit/ Codes Info By Cash rm d Date Service Re uest# Invoice# Well ID# Ma Lb , *L4105-0 YtD zktn- EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07 A * 141 o5 436, Is#-- - 2 2 -