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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes [XNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 I1%J"-r[tt UINUA13Lt rrKMII ',,ALL tCUZ0j V03-/gJr I -UR INSYtG ITUNS rAYIKtJ 7 TEAR PROM UATE ISSUED JOB ADDRESS 504 N. Golden Gate Ave. clTy/zIP Stockton 95205 CROSS STREET _ S. of E. Fremont St. APN 143-410-35 PARCEL SIZE 1 23LAND USE APPLICATION # OWNER John/Frank'Bailey PHONE 425-6757 John OWNER ADDRESS 504 N. Golden Gate Ave. CITY/STATEIZIP Stockton. CA 95205 CONTRACTOR Hennings Bros, Drilling Co Inc. PHONE 545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 C-67 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE 5-31-2020 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP �( 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 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 X 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 DlameterT Steel -inches Total Depth _ IDOL+ ft Depth to Water _ It Depth of Casin _ _ _ DES7 RIT-MON SPE( IFR '.ATION Sealing Material from 0 _ft bgs to b ,+/ft bgs Filler Material from _ R bgs FRE-CjEI D 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 t� �t L ^ L �� ❑ Explosives ❑ Detonating cord ❑ with projectiles every k r ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Omer SAN JOAQUIN CO JNTY Sealing Material Neat Cement (94 Ib bag / 5-6 gal water) Sand Cement sack mix / 7 gal water EPPptRit9NM L Bentonite (20% solids) X Manufacturer Spec % solids % Name Specs on File HEA PFFF IMPARI'D IENT Placement Method Pumped X 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. 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. CONTRACTORS MINIMUM 24 HOUR ADVANCE NOTICE T ffon, INSPECTIONS r' Vice President DATE Sept 27, 2018 14' a.b an.l one P1 MENT USE ONL Application Accepted By Date Area i Destruction Inspection By Date t! �� / Employee COMMENTS PE Sc Received hec Amount Permit/ Cod Info B ash a ed ate Service Re uest# Invoice # Well ID# o EHD 4306 WELL DESTRUCTION PERMIT 10/5/07