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WELL DESTRUCTION PERMIT 4 PUBLIC WATER SYSTEM ❑Yes QKNo 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 JOB ADDRESS 26554/26724 E. River Rd. CITYIZIP Escalon 95320 CROSS STREET E. of McHenry Ave. APN 247-200-19 PARCEL SIZE JQaLAND USE APPLICATION# O OWNER Adrian Family PHONE 596-6895-Joey OWNER ADDRESS 26554 E. River Rd. CITY/STATE/ZIP Escalon. CA 95320 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITYISTATErzIP Mnriastn, CA 9535fi C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31' 2020 PERFORATION CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 545-1185 PERFORATION CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZJP Modesto, CA 95356 Q( C-57 Well Drilling License Number 290813 Expiration Date_5/31/20 Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number n/8 Expiration Date CHP Hazardous Material Transportation for Explosives License Number n/a Expiration Date San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number n/a Expiration Date California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well [X Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent propertywith contamination(Address) Known Soil/Water contaminants at adjacent Property 4 EXISTING WELL CONSTRUCTION DETAILS 1Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes X No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_12__inches Total Depth 96 ft Depth to Water--63- ---ft Depth of Casing _90 ft bgs DFsTRC(-NON SPECIFICATION Sealing Material from 0 ft bgs to _96 ftbgs Filler Material _ from _ ft bgs to ft bgs Well casing to be perforated by one of the following methods: from 0 It bgs to 60__ft bgs ESC Mills Knife Number of cuts every 4 ft and/or 51 ❑ 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/b bag/5-6 gal water) Sand Cement 10-3 sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped XX 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 NOTI``C RE INSPECTIONS CONTRACTORS SIGNATURE , ISA+- a TITLE VP DATE Jan- 8, 2019 rLNI-4 I -- -14F�VF r SEE ATTACHED 9,glV !� _ OFAq F/yT<Nry I I J DEPORTMENT USE ONLY, I' Application Accepted By )� Date 4 Z�► Area _ I Destruction Inspection By Date Employee ID# ti i—r w COMMENTS PE SC Received Check#/ mount Permit/ Invoice# Well ID# Codes Info Remitted ADate Service Re uest# I IM EHD 4308 WELL DESTRUCTION PERMIT 10/5/07