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WELL DESTRUCTION PERMIT I Well#2 PUBLIC WATER SYSTEM ElYes IX No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS West�Testa-Rkl. 2AP55 derllec.l PW CITY/ZIP TraOV A5377 CROSS STREET S. of Grant Line Rd. APN 238-600-39 /', PARCEL SIZE 17 LAND USE APPLICATION# OWNER LTMT Trac LLCLewisD I ITl n kre J r cy. ,PHONE 91776-870-9569- Brown Const. Bruce y OWNER ADDRESS 1156 N. Mountain Ave Z11W jc r ul Tra( TrA-TATE2IP Upland, CA 91786 N CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Mndactn 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 Date r1/';119n 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 Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes IX 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 DFSI'RUC'TION SPECIFICATION Sealing Material from _D_ft bgs to 250__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 n1q 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/b bag/5-6 gal wafer) 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 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. MINIMUM 24 HOUgR ADVAI'CE NOTICE E I r' NSPECTIONS CONTRACTORS SIGNATURE �V\ V.P. DATE 5-31-18 SEE ATTACHED a _ FN y QU/ yFgCT. OE/yENTUN�Y ARTMF�� DEPARTMENT USE ONLY Application Accepted By A _ Date t'1' Area Destruction Inspection By Date Employee ID# I,,)C1'2 (N COMMENTS PE Sc Received Chec Amount D to PertnlU Invoice# Well ID# Codes Info Remitted Service Re uest# 4�ii ILI 1 EHO 43-08 WELL DESTRUCTION PERMIT 10/5107