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""ELL DESTRUCTION PERMI- PUBLIC WATER SYSTEM ❑Yes 'M No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTt:—,r PARTMENT 304 E WEBER..VE 3°n FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP Manteca 95336 French �Atr2� > CROSS STREET Camp Road APN9126 O �O PARCEL SIZ�` 3,L.AND USE APPLICATION# C O Wilbur Ellis Co . 982-5400 p OWNER PHONE OWNER ADDRESS 13771 South Prescott Road CITY/STATE/ZIP Manteca , CA 95336 y CONTRACTOR Clara Well , Inc. PHONE 209-462-7676 CONTRACTOR ADDRESS XOREN 2024 East Charter Way CITY/STATE/ZIP Stockton , CA 95205 ❑ C-57 WELL DRILLING LICENSE NUMBER 371560 EXPIRATION DATE—0 4/0 6 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ 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 C► 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 9( Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes A No Grout Seal b 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 v Well Casing Diameter 12 inches Total Depth 87 ft Depth to Water 38 ft Depth of Casing ft bgs 1 DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to 87 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 4 Number of cuts every 1 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) X Sand Cement 1 n . 3 .rack mix/7 gal water ❑ Bentonite Pellets ❑ Bentonite(20%solids) ❑ Manufacturer Spec%solids_% Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other Seal Completion Y Complete with Mushroom Cap ft bgs ❑ Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINA CELIFO A NTRACTOS, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WI T E CARS S TE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION k#. MI 2 N CE EQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE Sac-Tres DATE 13 Jan 06 i — - _ i ` pM 2 �7� - �- Q7 - — - RECEIVE} [37 _ I JA1� � ?_006 r t SAN JOAOUtN!COUNFY ENVIRONMENTAL J HEALTH DEPARTMENT DEP RTMENT USE Application Accepted By Date / Area Destruction Inspection By Date '� D Employee ID# COMMENTS PE SC Received C Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# s q� 3 � 3 06 Koo L-1 5-L4 EHD 43-02-008 Wc11 Destruction Permit 1/271'2005