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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 Joe ADDRESS 18707 Von Glahn Avenue CIT./Zjp Escalon 95320 CROSS STREET Yosemite APN 245-080-52 PARCEL SIZE LAND USE APPLICATION # OWNER Kenneth Hill PHONE 209-603-8576 OWNER ADDRESS 18707 Von Glahn Avenue CITY/STATE/ZIP Escalon 95320 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Road CITY/STATE/ZIP Modesto, Ca. 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE 05/31/2020 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date 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 ❑ PitWell ® 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 ❑ 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 _ inches Total Depth _ft Depth to Water ft Depth of Casing It bgs DESTRUCTION SPECIFICATION r Sealing Material from 0 It bgs to 180 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 it bgs ❑ Mills Knife Number of cuts every ft and / or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ With projectiles every ft ❑ without projectile ❑ other Sealing Material Neat Cement (941b bag / 5-6 gal water) Sand Cement sack mix / 7 gal water Bentonite Pellets x Bentonite (20% solids) Manufacturer Spec % solids % Name Quik Grout Specs on File Specs Submitted Placement Method x Pumped Free Fall Other Seal Completion Complete with Mushroom Cap it bgs x 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. MINIMUM 224 HOUR ADVANCE NTIIICE REQU R DAPOR INSPECTIONS CONTRACTORS SIGNATURE`4{XVlWLtld'. Jafla" DATE 02-26-19 Application Accepted By _ Destruction Inspection By COMMENTS DEP ARTMENT USE ONLY / �q `/ Date �I Area �(r Date Employee ID# PE SC Received hec Amount Date PertnlU Invoice # Well ID# Codes Info s Remitted Service Re uest# EHD 43-08 10/5/07 WELL DESTRUCTION PERMIT