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r ! WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes E9 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95206-6232 -(209)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ` JoBAOOREss le°nn _IrH�JAv"+r�g� �clrrlLp LODL CA 95242 CROSS STREET _ApN 055-020-028-898,+__PARCEL SIZE 1?•DLANO USE APPLICATION N OWNER GRINDSTONE JOE ASSOCIATION PHONE (650)279-0242 OWNER ADDRESS 1029N COUNTRY CLUB BLVD. Cm/STATEIZIP STOCKTON,CA 95204 CONTRACTORDREW 8 HEFFNER WATER WELLS&PUMPS PHONE (559)645-2483 p rQ CONTRACTOR ADDRESS 26452 AVENUE 17 1/2 CITYISTATE21P MADERA,CA 93638 o C-67 WELL DRILLING LICENSE NUMBER 1003754 A_�ExPiRA noN DATE 05/31/2021 PERFORATION CONTRACTOR�_y r �) I 'L PERFORATION CONTRACTOR ADDRESS i�3 11 A �11i A_i� CITY/$TAIE/ZIP t 1 ,Lfs��e ✓ — Itxi37;< QS13 i'109� D 63y C•57 Well Drilling L.42n5e Number Bureau of Alcohol.Tobacco and Firearms-US01S Of I tigh I.aplOswes License Number F.-apiralron UatO CHP Hazardous Material TransponabOn for Explosives License Number __ Expiration Date. at rn San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date o California Occupational Safety Health-Blaster License Number Expiration Dale i0 REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ best Hole O Detected I Suspected Well Water Contaminant(S) NIA - C) Adjacent property with contamination(Address) NIA _ D Known Sail I Water contaminants at adjacent property NIA -- r N EXISTING WELL CONSTRUCTION DETAILS VJ Open Bottom fJf Gravel Pack Cl Untased ❑ Other Well Log copy attached ❑ Yes t� No Grout Seal (3 NO 1: Yes h below ground surface(bgs/ Hole Diameter iO menus Well Conductor Casing❑ Yes C� No Depth of Conductor Casing_.____h bgs Diameter of Conductor Casing _ orches Well Casing Diameter- 6 .._ inches Total Depth-..175 —% Depth to Water 70 R Depth of Casing ft bga 77s . nr.,TRt-(-TI(1\Sr ECIFICA TION Sealing Material from _- I bgs to _ C bgs Filler Meterlal�Q �f_ m -.--- ft bgs t0 -----.. -_h bgs Well casing to be perforated by one of the following methods:_ from It bgs to R bgs ❑ Mills Knife Number of cuts every ft and I or — /a Exptosive3„2"'Detonating card ❑ with projectiles every _ .._ f1 .01ewlthout projectile ❑ Detonating cord and boosters O with projectiles every_ _. _ft ❑ without projectile C Sealing Material Neat Cement(941b bag 15-6 gal water) ,Sand Cement ..'tj..sack mrx 17 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spnc%solids _ % Name .,., +� /' Spats c^Gd Specs Submits. Placement Method Pumped Free Fall Other L,(,Z�[}C'C - y/''t�1� Seat Completion Complete with Mushroom Cap__-- ____-. .N bgs Complato to Existing urface 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 ND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND THE C ORNIA C RACTORS STATE LICENSE BOARD AND THAT"I AM IN COMPLIANCE WITH AI-L WORKERS CO NSATION LA MINI UM 48 HOUR ADVA CE NOTICE REQUIRED FOR INSPECTIONS 2 CONTRACTORS TORE ~ TITLE`� i DATE I I I PAYtIVED ENT RE JUL5 2019 SAN JOAO AN COUNTY ENVIRC 4MENTAL HEALTH PARTMENT TMENT USE ONJY APphcaaon Accepted By _-- _._-__._ Date _�j,'x/ _ _ Area Destruction Inspection BY_- Date^ ?'tom'' - — Employee IDN_. P'„""� __'_- COMMENTS __ -- / PE SC Received Amount ate Perrnit/ Invoice N Well IDN Codes Info ash Remige Service Request 0 117 WELL DESTRUCTION PERMIT EHD 43-08 revised 4'14178