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WELL DESTRUCTION PERMIT r PUBLIC WATER SYSTEM ❑Yes nNo 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 JOBADDRESS 240 E. Edison Street clTYrcIP Manteca. CA 95336 CROSS STREET Lincoln Ave. APN 223-142-03 PARCEL SIZE_JZLAND USE APPLICATION# C OWNER PeneloieCornish c/o BMW Development PHONE 456-0190 Bruce Barber OWNER ADDRESS_ 158 N. Main St, CITYISTATE/ZIP Manteca. CA 95336 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. cITYIsTATEIZJP Modesto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2020 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZJP p( C-57 Well Drilling License Number 290813 Expiration Date 5/31/20 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 [X 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 ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes IX No Grout Seal ❑ No ❑ Yes _ _ft below ground surface logs) Hole Diameter _ inches Well Conductor Casing❑ Yes lX No Depth of Conductor Casing __ft bgs Diameter of Conductor Casing_ inches Well Casing Diameter_ inches Total Depth _ft Depth to Water ft Depth of Casing _- ft bgs DE.Sh'RUCTION SPECIFICATION Well Depth..26' Sealing Material from ___O_ft bgs to 26 ft 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 XBentonite(20%solids) Manufacturer Spec%solids % Name QUIk Grout Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 4 It 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 NOTICE REQUI D FOR INSPECTIONS CONTRACTORS SIGNATURE � SVice President DATE April 26. 2019 _ I PA HENT - R EIVED AY 117 2019 NVISqN ORp !N COUNTY HEALTH DEJ AENTAL RTMENT PARTM ENT USE ONLY Application Accepted By _ Date7/1 Area (` Destruction Inspection By Z Data Employee to#r COMMENTS PE SC Received hoc Amount Date Perm1U Invoice# Well ID# Codes Info By ash Remitted Service Re uest# EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07