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v v FELL DESTRUCTION PERN PUBLIC WATER SYSTEM ❑Yg)<No SAN IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'u'FLOOR-STOCKTON CA 95202 - (209)46`8-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES.I YEAR FROM DATE ISSUED JOBADDRESS 26639 E. JONES RD '- A�dN t-7- lev-03 CITY/ZIP E S C A L 0 N 95320 m 19 OWNER ROCHEBROS. I� ' 7 �� PHONE 601 -5300 . tv OWNER ADDRESS 26639 E. J O N E.S P D. CITY/STATEIZIP E S C A L O N, CA 95320 CONTRACTOR MENNINGS BROS. DRILLING CO. , INC. PHONE 545-1185 CONTRACTOR ADDRESS 3525 P E L A N D A L E AVE, —CITY/STATE/ZIP M O D E S T O ,CA 95356 IN C-57 WELL DRILLING LICENSE NUMBER 2 9 0 8 13 EXPIRATION DATE 5-31 -06 PERFORATION CONTRACTOR PHONE SCA PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP bX C-57 Well Drilling License Number 290813 Expiration Date 5-3 1 -0 6 ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date i ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration pate i ❑ 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 [3 Replacement Well ❑ Caved In ❑ Pit W lifftive [] Test Hole i Detected/Suspected Weil Water Contaminant(s): Adjacent property with contamination (Address): Known Soil/Water contaminants at adjacent property: i EXISTING WELL CONSTRUCTION DETAILS C3 OpenBottom 13Gravel Pack ❑ Uncased 13 -Other. PUMP IN WELL Well Log copy attached ❑ Yes d No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches 4�% Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches V+ Well Casing Diameter 6-8 inches Total Depth ? ft Depth to Water ft Depth of Casing? ft bgs DESTRUCTION SPECIFICATION I Seating Material from 0 ft bgs togs 2 ft b Filler Material 2 from b 01;t o til ft bgs to ft bgs Well casing to be perforated by one of the foliowini=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 j C] Detonating cord and boosters: ❑ with projectiles everyft ❑ without projectile S"F �• ��, - ❑ Other Sealing Material ❑ Neat Cement(94 Ib bag/5-6 gal water) X7 Sand Cement 6 sack mix/7 gal water ❑ Bentonite Pellets CK Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method (Pumped Q Free Fail ❑ Other INSIDE Seal Completion: ❑ Complete with Mushroom Cap ft bgs Xa Complete to Existing Surface PadP U M P H O U SE 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 - ND.AVE� CTI -WIT1 . H�li'ORiSiAeONTRA RS ST,%TE hIeEN I-A-M--tN-COM-PLtANCE1Vf`PH-ALL WORKERS COMPENSATION LAWS. i MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATOR m I LE. S U P E RU T OS R DATF4. 9 LQ. 05 % i I - I u n I N E WDDE EECH M NTi D+PARTMENT USE ONLY t Application Accepted ByDate _ ��S��`� Area / -Zia �G Destruction Inspection By Date � /a' �cc, Employee 1D# T��p COMMENTS r I PE SC Received Amount Permit/ Codes Info B Cash Remitted Date Service Re uest# Invoice# Well IDtt S" _000 ,. £HD41-02-008 6tVO4 Well DcstructiomPcrmit Addendum dfiO4 1c 6-9-04