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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ($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 y JOBADDRESs 626 E.Augusta St. CITY/ZIP Wondbridfpa, CA 95256 CROSS STREET W. of Chestnut St. APN 015-100-25 PARCEL SIZE LAND USE APPLICATION# OWNER Rmmnn Nava rJp Arrant HpmPs of Mantpra PHONE 823-1751 Matt OWNER ADDRESS 2204 E.Yosemite Ave. CITY/STATE/ZIP Manteca. CA 95336 CONTRACTOR Hennings Bros. Drilling Co.. Inc. PHDNE 545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Mndasto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE 5-31-2020 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP p( C-57 Well Drilling License Number 290813 Expiration Date 5-31-90 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 (X Inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) 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 ❑ No Grout Seal ❑ No ❑ Yes ft 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 Diameter__ inches Total Depth unknown Depth to Water_ ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to _ __ft bgs Filler Material __ from__ _ _ft bgs to ft bgs Well casing to be perforated by one of the following methods: from It 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 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) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall }� Other CPmpnt Can 30°X 12" at 4' below Seal Completion Complete With Mushroom Cap " IAl bgs Complete to Existing Surface Pad surface 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 It^� �ADVANCE NOTICE RE R INSPECTIONS CONTRACTORB$IGNATURE`' ►�"��.� �� TITLE Vice-President DATE 3-15-19 R1� 2019 -SME 11.71=HEII � TMFNT P TMENT USE ON VY Application Accepted By Date Area v� Destruction Inspection By Date Employee I COMMENTS �C7 PE SC Received hoc Amount Date Permitl Invoice# Well ID# Code* Info By— Remitted Service Re uest# 15 1 1 7" EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07