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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 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 811 W. River Rd. CITY/Zip Ripon 95366 CROSS STREET East of Fulton APN 245-340-35 PARCEL SIZE JR_?6ND USE APPLICATION# OWNER City of Ripon C/o DeGraff Development PHONE 841-0541 OWNER ADDRESS 501 S. Stockton Ave. CITYISTATEIZIP Ripon, CA 95366 CONTRACTOR Hennings Bros. Drilling Co.. Inc. PHONE 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/E PERFORATION CONTRACTOR ADDRESS C-57 Well Drilling Bureau of Alcohol. Tobacco and Firearms - Users of High Explosives CHP Hazardous Material Transportation for Explosives San Joaquin County Sheriff -Coroner Explosives Application and Permit California Occupational Safetv Health - Blaster CITY/STATE/ZIP License Number 290813 License Number License Number License Number License Number Expiration Date 5-31-20 Expiration Date Expiration Date Expiration Date Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well CK Inactive ❑ Test Hole Detected / Suspected Well Water Contaminangs) 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 jig Yes ❑ No Grout Seal ❑ No Yes 50 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__ inches Total Depth 137 ft Depth to Water It Depth of Casing 137 It bgs Sealing Material from 0 ft bgs to 137 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 ft and /or ❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material Neat Cement (94 /b bag / 5-6 gal water) Sand Cement 10.3 sack mix /7 gal water Bentonite Pellet Bentonite (20% solids) Manufacturer Spec % solids_ % Name Specs on File Specs Submitte1C. Placement Method X Pumped Free Fall Other �J 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 �I JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENS is CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVAN Application Accepted By _ Destruction Inspection By COMMENTS INSPECTIONS TITLE V.P. DATE 12-6-18 PE SC Received Chec Amount Permit/Cod Info ash a ed Date ervice ues # Invoice # Well ID# 21 2 --HD 43-08 �'! � dC.J WELL DESTRUCTION PERMIT 10/5/07 rn m a D s H �kF