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WELL DESTRUCTION PERMIT r '/ 2 Well Abandonments PUBLIC WATER SYSTEM El Yes XNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL/205 J52-7697 FOR INSPEC 1 iONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS 1124 Pescadero Ave. (1137 E. Grant Line Rd.) cITY21P Tracy 95304 CROSSSTREET E. of MacArthur Dr. APN 213-070-81 PARCEL SIZE-3,5,82ND USE APPLICATION# O OWNER IPT Tracy DC IV LLC PHONE 949-892-4911 H OWNERADDRESS 4675 MacArthur Court, Suite 625 CITYISTATE/zIP Newport Beach, CA 92660 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATEIzIP Modesto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2020 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEIIJP 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 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 i){ No Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes ]ZII 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 O ft bgs to E8t-_59'ft 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 It and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating Cord and boosters ❑ with projectiles every _ ft ❑ without projectile ❑ Other Sealing Material Neat Cement(941b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets X Bentonite(20%solids) Manufacturer Spec%solids_% Name BarlOd Ulk Grout Specs on File Specs Submitted Placement Method X Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 4 It 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. ��oVi� r!INRFUM 74 HOUR..ADVANCE NOTICE REODU R hISPECTIONS CONTRACTORS SIGNATURE TITL9 NV.P. DATE Aug. 6,2018 PAYWp NT SEE ATTACHED - RECel eo AUG p 7 4,018 SAN JOAQUIN CN EAMR0HEq� o SN TY EPART ENT ENT USE O Application Accepted By Date Area Destruction Inspection By %+ Date Employee I COMMENTS , t,4/(2, PE SC Received Check#/ Amount Permit/ Codes Info By Cash mi d Date Service Re uest# Invoice# Well ID# Io5O 71 co 35 EHD43-08 �7-� WELL DESTRUCTION PERMIT h0/5/D; CA 1 oSb 431,e V1 zz -