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V/N WELL DESTRUCTION PERMITPUBLIC WATER SYSTEM ElYes ElNo N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 ON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Da ADDRESS E OIll stock RD CITYIZIP S t O c ICton , CAROSS STREET B e e c h e r APN 08913028 PARCEL Stzej O' D USE APPLICATION# WNER Brittilia Ventures/",:-( � ,7 n 95236 � OWNER ADDRESS P O B O X 17 0 -)/q /V &I l�I CITYISTATEJZIp L l n It e n� C A 9 5 2 3 6 CONTRACTOR PurvianrP Dri11Prs , TNr PHONE-2-0-9-RR 7-'15 4 CONTRACTOR ADDRESS CITYISTATEIZIP TL/iy n d (e n f "A 95236 C-57 WELL DRILLING !LICENSE NUMBER�//'' 13 EXPIRATION DATE ,� PERFORATION CONTRACTOR 7PHONE PERFORATION CONTRACTOR ADDRESS/'Tnn CITY/STATEIZIP L12 /y` 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 Pit 1!I ❑ Inactive ❑ Test Hole / Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property ('Q 1 40A r Y EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased Other / Well Log copy attached ❑ Yes I!k-No Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes 5�'No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter )V;+ Total Depth ft Depth to Watery/S,u� Depth of Casing ft bgs (4�/ DESTRUCTION SPECIFICATION - L' Sealing Material from 0 ftbgs to C13-- ftbgS Filler Material___ from ft bgs to ft bgs ( Well casing to be perforated by one of the following methods: from ft 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 Ib 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 Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THEW RK 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. I MI UM 24 HC A VANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TIS Secretary DATE 9/28/18 131 -� ANENT -- - - - - _ SCEIVED - - -- �CT 5 2018 SAN _I- ENVIRONJOAQ ENTIJN�, -- - - _. - H�ALTN p AL E NT TME AT NT USE ONLY Application Accepted By- Date ( � Area Destnlction Inspection By Date Employee ID# COMMENTS PE SC Received Check#/ Amount Date Permit! Invoice# Well ID# Codes Info B Cash Remitted Service Re uest# EHD 43-08 WELL DESTRUCTION PERMIT 1015107