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WELL DESTRUCTION PERMIT ' t - PUwJC WATER SYSTEM ❑Yes XNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED n JOBADDREss 2448 Kettleman Road ciTyizip Lodi 95240 M CROSSSTREET Sacramento Road APN 058-140-01 PARCEL SIZE 0.5a LAND USE APPLICATION# Z OWNER Tesoro Sierra Properties LLC PHONE 253-896-8700 � ~ OWNERAOORESS 300 Concord Plaza Dr. CITYISTATEIZIP San Antonio,TX 78216 CONTRACTOR Greg Drilling PHONE 925-313-5800 4,00)m r-" CONTRACTOR ADDRESS 950 Howe Road CITY/STATEIZIP Martinez CA 94553 rn 2-P P-- C-57 WELL DRILLING LICENSE NUMBER 485165 EXPIRATION DATE 0112010 Z Q PERFORATION CONTRACTOR PHONE S� PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP t ❑ C-57 Well Drilling Lice ise Number Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives Lioe se Number Expiration Date CHP Hazardous Material Transportation for Explosives License Number Expiration Date San Joaquin County Sheriff-Coroner Explosives Application and Permit Lice se Number Expiration Date California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well p Caved In ❑ Pit Well X Inactive ❑ Test Hole Detected!Suspected Well Water Contaminant(s) trace MTBE Adjacent property with contamination inaon(Address) Known Soil/Water contaminants at adjacent property -- EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased X Other PVC CaSIRCI Well Log copy attached ]8( Yes ❑ No Grout Seat ❑ No X Yes 37 It below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes )8( No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 2 inches Total Depth 60 ft DepthtoWater 50 It Depth of Casing 60 It bgs DESTRUCTION SPECIFICATION Sealing Material from 2 ft bgs to 60 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 it bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating card and boosters ❑ with projectiles everyft ❑ without projectile ❑ other Sealing Material FNeat Cement 941b bag/5-6 gal water) Sand CLmeni sack mix 17 gal water Bentonite Pellets Bentonite 120%solids) acturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped ' F yy Other DreSSUre OrOUt Seal Completion Complete with Mushroom Ca p ^7 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 REGULATI N5. 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. M IMUM 24 O R ADVA =NOTICE'REQUIRED FOR INSPPEC/T,I/,e/O��NyS� �CONTRACTORSSIGNATURE TiTLf Oji[ /�/ViY/lIATE WXCVj�2 [� DEPARTMENT USE ONLY Application Accepted By F Data I 0 Area Destruction Inspection By Dae K! Employee ID# � l COMMENTS PE SC Received Check* Amount Date Permit! Invoice# Well ID# Codes Into B Cash Remitted Service Request# So o bac'' 1.o S hr a /'PJI EHD 43-08 WELL DESTRUCTION PERMIT 1075107