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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 m JOB ADDRESS 225 Swanson Rd. cnryizip Manteca. CA 95337 CROSS STREET N. of Yosemite Ave. APN 19f3-179-37 PARCEL SIZE_��LAND USE APPLICATION# C OWNER Sunny Valley Smoked Meats PHONE 601-1801 Marvin OWNER ADDRESS P.O. Box 2158 CITYI$TATEIZIP Manteca, CA 95336 CONTRACTOR Hannings RrnG nrillin9 ( n , inr. PHONE 545-1185 CONTRACTOR ADDRESS 1 9.39 I add Rd. CITY/STATE/ZIP Modesto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2020 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP C-57 Well Dnlling License Number 290813 Expiration Date 5/3 1/29 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 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 JK Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes X No Grout Seal ❑ N,, ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes ❑ No Depth of Conducto asing ft bgs Diameter of Conductor Casing _ inches Well Casing Diameter 6"Steelinches Total Depth_3alrit Depth to Water .__ ft Depth of Casing 131 ft bgs DESTRUCTION SPECIFICATION Sealing Material from Oft bgs to —12fft bgs 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 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids)X Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped X Free Fall Other Seal Completion Complete with Mushroom Cap 4' 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 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 ADVANCE NOTICEE�REQUI .SPECTIONS CONTRACTORS SIGNATURE V v E V_ P. DATE Nov. 28 2018 I � SEE ATTACHED -10 — o��co49 --I FpgRT Tq��ry D PARTMENT USE ONLY Application Accepted By I A Date I Z 410/9 Area Destruction Inspection By Date Em loyee IDI# COMMENTS o tiv .. c M "/ .S LI µ�l✓�Si,/1 I 10 In t F ,LNec( de&fr o "d Pry Rai. Aft fpdsvr�- PE Sc Received eck#/ Amount Date PertnlU Invoice# Well ID# Codes Into B Remitted Service Re uest# t G D- �, ,� t ��10 10/55/04&OB ��-', e1c /�`/��" �� WELL DESTRUCTION PERMIT