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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [XNo 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 1051 Robert Ave. CITY/LP Ripon, CA 95366 ��, CROSS STREET N. of Baily Dr. APN 259-,0t90-07 f� PARCEL SIZE J-CaAND USE APPLICATION# p OWNER Todd AhV- / I El --6� 4n A h Jif PHONE OWNER ADDRESS 1051 Robert Ave. CITY/STATE/ZIPRipon- CA 95366 FF"" CONTRACTOR Hennings Bros.Chilling Co lnc PHONE 545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 ExPIRATION DATE 5-31-20 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP IX 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 aQ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s)I nw IPveJ of T(F and ("s, I7(:F hgyp s@nnestiAg tO City lit �' Adjacent property With contamination(Address) been deteCtpd In th*s Well sinnp 2010 and Known Soil/Water contaminants at adjacent property-have-been rhacreasing 20-1.A h iIy_lahj_rnpr)rt.1S-aaarhed. ExisTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ 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 Well Casing Diameter_ 6 _ inches Total Depth 1_40 _ft Depth to Water ft Depth of Casing ft bgs PA Y41, ` DESTRUCTION SPECIFICATION - --�- - - Nr Sealing Material from Oft bgs to 140 ft bgs Filler Material_ from ft bgs to ft bgs ��/V�D Well casing to be Perforated by one of the following methods:__ _ from It bgs to ft bgs /f� ❑ Mills Knife Number of cuts every ft and/or U ❑ Explosives❑ Detonating Cord ❑ with projectiles every ft ❑ Without projectile S O �0, ❑ Detonating cord and boosters ❑ With projectiles every _ ft ❑ without projectile A ❑ Omer N RONM C�UN Sealing Material X Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pe FN �' Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Of pART fe Placement Method X Pumped Free Fall Other MFNr 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. 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 REGI R_D INSPECTIONS CONTRACTORS SIGNATURE ` • TITLP- DATE 8-19-20 i � I � _ I b c abandon CJ �( 1 i T---! -1_-- I— o 14 - -- Is A R ENT USE O P1 4. Application Accepted ByDate 17 Area Destruction Inspection By Date Employee ID# COMMENTS ' 7p, Lz PE SCReceived Chec Amount Permit/ Codes I to B Remitted Date Service Re uest# Invoice# Well ID# � .70 EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07