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WELL DESTRUCTION PERMIT <br /> f PUBLIC WATER SYSTEM ❑Yes [X No <br /> f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> JOB ADDRESS 1124 Pescadero Ave. cITY/zIP Tracy 95304 <br /> CROSS STREET W. of MacArthur Drive APN 213-070-81 PARCEL SIZE9.74!_AND USE APPLICATION# <br /> OWNER IPT Acquistions, LLC PHONE 925-989-0888 Fermin Ramirez <br /> v, <br /> OWNERADDRESs 4675 MacArthur Court, Suite 625 CITY/STATE/ZIP Newport Beach, CA 92660 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATEIZIP Modesto, CA 95356 <br /> C-57 WELL DRILLING LICENSE NUMBER 290813 ExPIRATION DATE May 31, 2020 <br /> PERFORATION CONTRACTOR n/a PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C-57 Well Drilling License Number 290813 Expiration Date 5-31-20 <br /> Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) <br /> Known Soil/Water contaminants at adjacent property <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes X No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter_ inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter8 inches Total Depth 25'+_. It Depth to Water ft Depth of Casing - ft bgs <br /> DESTRUCTION SP ECH`I(AIION <br /> Sealing Material from .eft bgs to bZO_U=ft bgs Filler Material from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods, from It bgs to ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94/b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets <br /> Bentonite(2 h solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement Method Pumped Free Fall Other Pump cement if well is deeper r than 30' <br /> Seal Completion Complete with Mushroom Cap 4' It bgs Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICES REQU1 F R INSPECTIONS Nov.ONTRACTORS SIGNATURE .L.aLf / ITL VP DATE_ry1 2018 P <br /> AN'/O ?®p8 <br /> h' F'VV1 Q0/N <br /> - — — SEE ATTACHED _ TN 4'pMF,`,2 <br /> OA,7), <br /> I <br /> I <br /> I <br /> DE`P RTMENT USE ONLY <br /> Application Accepted By Date _L /- Area •t/ <br /> Destruction Inspection By Date f- Employee ID#_ rl„�,�1+-1� <br /> COMMENTS <br /> I d <br /> PE IS. <br /> Received Check#/ Amount Permit/ <br /> Codes Info B emitted Date Service Request# Invoice# Well ID# <br /> -41173 1 W 00 1 <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 10/5/07 <br />