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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No 1 SAN JOAouiN 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 ADDRESS11418 t, EComstock R D CrrY1ZIP Stockton, CA 01'5 /5 I�/I✓ / CROSS STREET B e e c 11 e r APN 08913028 PARCEL SMj o- D USE APPLICATION# b Brittilia Ventures/1—uetn r OWNER --7 /J� n A n �j G OWNER ADDRESS PO Box 170� /�g � lkl Jed CITY/STATEIZIP L i n d P_n , -1.A 9 S 2_7 6 ' y CONTRACTOR P u ry i a n r P D r i 1 1 P r s , T N r PHONE 9(19—8 8 7—'15 51, CONTRACTOR ADDRESS ,{ CITY/STATE/ZIP Linden , C A 95236 C57 WELL DRILLING LICENSENUMBER IJ ExPiRATION DATE PERFORATION CONTRACTOR ♦/yr PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATEI21P 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 'X Pit t/1 ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property y EXISTING WELL CONSTRUCTION DETAILS [3Open Bottom ❑ Gravel Pack (3Uncased r Other - d Well Log copy attached ❑ Yes Er No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches f Well Conductor Casing❑ Yes 3�'No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter--Adj--inches Total Depth ft Depth to Water /W Depth of Casing It bgs V DFSTRUCITON SPECIFFICATION I l Sealing Material from t) 1t bgs to 2— 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 f 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(94/b bag/5-6 gal wafer) Sand Cement /u 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 Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THEW RK 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 t AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. I �MIUMA VANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE T,. Secretary DATE 9/28/18 i r -. - - 1e - - A MENT I Qty _ - __ _- - - - -��_EIV�� / - - 5 20f8 _ V p IN -- - --' HEAL TH pE NT L TMENT EPA TMENT USE O/NLY ,{y Application Accepted By. Date C = ✓ Area�I- Destruction Inspection By Date Employee ID# 11-17 /V Z717A.In COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# Codes Info By Cash Remitted Service Request# EHD 43-08 WELL DESTRUCTION PERMIT 1015107