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WELL DESTRUCTION PERMIT • PUBLIC WATER SYSTEM ❑Yes IX No Well#1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT �p� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS -West end-of- T[Cl. T�— Fi-rW)eVCITY/LP Trar,V M.177 CROSS STREET S. of Grant Line Rd. APN 238-600-39 PARCEL SIZE LAND USE APPLICATION# C OWNER LTMT Tracy, LLC Lewis Devqlopment �T 1 J-1 ttC- p ONE 916-870-9569- Brown Const. Bruce y OWNER ADDRESS z4c) I�c'7 ci TA ILP Upland, CA 91786 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITYISTATEIZIP Mn(1Pstn CA 85356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31,2020 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP IX C-57 Well Drilling License Number 290813 Expiration Date 5/31/7n 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 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 Peck ❑ Uncased ❑ Other Well Log copy attached ❑ Yes [y, No Grout Seal ❑ No ❑ Yes_ ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes X No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ 6 inches Total Depth eSt.250t Depth to Water _ ft Depth of Casing _ ft bgs DESTRU FIOIN SPECIF'IC'ATION Sealing Material from �_ ft bgs to 250 ft bgs Filler Material _ from ...... ftbgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife n/a 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 ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids)X Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped X Free Fall Other Seal Completion Complete with Mushroom Cap 4 ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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. Pp��'MINIMUM 24 HOUR ADVANCE NOTICE EQ FOR INSPECTIONS CONTRACTORS SIGNATURE ' In V-P- DATE 5-31-18 `b SAro J 2018 Nom /pE MENTA NrY ART NT SEE ATTACHED I ME / PARTMENT USE ONLY Application Accepted By �� Date 6 / Area 5 / T\r✓�c.-� ,n Destruction Inspection By Date O Employee ID# I UCA� (/X//Y 1. COMMENTS PE SC Received Check#/ Amount D to Permit/ Invoice# Well 1D# Codes Info B Remitted Service Re uest# EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07