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` WELL DESTRUCTION PERMIT ' PUBLIC WATER SYSTEM ❑Yes [9 No 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 E. Mariposa Rd. CITYIZIP Stockton 95215 m CROSS STREET N. of Austin Rd. APN 179-220-36 PARCEL SIZE79 GLAND USE APPLICATION# 0 OWNER Norcal Landco LLC c/o JBS Builders Inc. PHONE 916-240-8325-Jeff Smith y OWNERADDRESs 3853 Taylor Rd., Ste. 400 CITY/STATE/ZIP Loomis. CA 95650 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITYISTATEIZIP Modesto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2020 PERFORATION CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 PERFORATION CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto. CA 95356 IX C-57 Well Drilling License Number 290813 Expiration Date 5-31-7(1 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 Contaminants) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS CK Open Bottom 1 Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes IX No Grout Seal ❑ No ❑ Yes _ -ft below ground surface(logs) Hole Diameter inches Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 14" ID inches Total Depth 51 7 If Depth to Water_-80 ft Depth of Casing 484 ft bgs DESTRLCr1ON SPECIEICAnon Sealing Material from _0 ft bgs to _100 ft bgs Filter Material -Birdseye Gravel from 100 ft bgs to 517 ft bgs Well casing to be perforated by one of the following method from ft bgs to ft bgs X Mills Knife top 100' Number of cuts every---'+ ft and/or ❑ Explosives❑ Detonating cord ❑ it 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 10 3_sack mix/7 gal water Bentonite Pellets Bentonite(209 solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pumped XX 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 HOUR ADVANCE NOTICE REQUIRED F INSPECTIONS CONTRACTORS SIGNATURE 9-t-" 5 T E V.P. DATE Nov. 6, 2018 AYMIlMENT — — ECEIVE� e �V 0 7 2018 - SAN OAQUIN COUNTY ENVIRONMENTAL -- -- - --- - Ht ..TH DEPARTMENT FPA TMENT USE ONL ® �/ Application Accepted By Date Area G Destruction Inspection By Date Employee ID# COMMENTS PE SC Received Check#/ Amount Permit/ Codes Ifo Cash emitted Date Service Re uest# Invoice# Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07