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WELL DES_TI ZUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [XNo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m JOBADDRESS 27022 S. Corral Hollow Rd. clTY/zIP Tracy. CA 95377 CROSSSTREET S. of Valpico Rd. APN 244-030-05 PARCEL SIZE 1 17AND USE APPLICATION# to OWNER Kevin Henshall PHONE 208-920-0123 y OWNERADDRESS 27022 S. Corral Hollow Rd. CITY/STATE/ZIP Tracy, CA 95377 CONTRACTOR HeLloingS RrnS nrllllnrq Cn Inr-, PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd CITY/STATE/ZIP Modesto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 ExPIRATION DATE May 31, 2020 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 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 IL[ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent propertywith contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes X No Grout Seal ❑ No fX Yes_50_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_6 5/8 inches Total Depth_J-02 ft Depth to Water ft Depth of Casing 102 ft bgs DESTRUCTION SPECIFICATION pump stuck in well will pump cement Sealing Material from Oft bgs to �_� (t 6�s�EiI1iMaterial from ft bgs to ft bgs Well casing to be perforated by one of the o Iowr�ne�NN Aig s:S Dl6 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 XNeat Cement(94/b 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 X Pumped 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. 1 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 74 HOUR ADVANCE NOTICD FOR INSPECTIONS CONTRACTORS SIGNATURE `0 V!tCTITLE V.P. DATE May 2,2019 _ - PA MENT { SEE ATTACHED PLOT MAP- - MAY 1 2019 NV'ROANEA DE TN MENTAL I ARTMENT , DEPARTMENT USE ONLY Application Accepted By Date ?hg Area Destruction Inspection Byb�— Date Employee ID# f COMMENTS PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Inf B Cash Remitted Se ' e Re uest# EHD 43-08 WELL DESTRUCTION PERMIT 10/5107