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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes R No 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 JOB ADDRESS 28488 Bird Rd. cITYIZIP Tracy, CA 95304 CROSSSTREET S. of Ahern Rd. APN 239-200-13 PARCEL SIZE2�3LAND USE APPLICATION# OWNER KomalDreet'Atwal L�fC� PHONE 321-0826 y OWNER ADDRESS 3701 W. Linne Rd. —CITY/STATE/zip Trac, , CA 95304 CONTRACTOR Hennings Bros, Drilling Co., Inc. PHONE 545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITYISTATE/ZIP Modesto, CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE 5-31-20 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP 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 I)( Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property_ v — EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom IX Gravel Pack Cl Uncased ❑ Other Weil Log copy attached ❑ Yes X No Grout Seal ❑ No a( Yes 710 ft below ground surface(bgs) Hole Diameter 14 _inches Well Conductor Casing❑ Yes IX No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 8 __inches Total Depth 420 ft Depth to Water_ _ ft Depth of Casing 420 ft bgs DtsTRerrlos SPE(IFH ATloh r Sealing Material from 0 ft bgs to 420 ft bgs Filler Material_ m ft bgs to ft bgs \ Well casing to be perforated by onb of the following methods, m ft bgs to ft bgs �✓ ❑ Mills Knife Number is everyft and/or ❑ Explosives❑ Detonating cord ❑ with projectile ery ft ❑ without projectile `^ ❑ Detonating cord and boosters th p iles every It ❑ without projectile I r ❑ Other Se ing Material Neat Cement(94 Ib bag/5-6 g ter) d Cement sack mix/7 gal water Bentonite Pellets ntonite(20%solids) Manufacturer c%solids_°h Na Specs on File Specs Submitted Placement Method XPumped / Free Fall Iher Seal Completion Complete with Mu(sliiroom Cap 4 It 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. VY MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE Com— TITLE V.P. —DATE.--—AD[.-5-2019 ,p �4, n I IF s ®6 2019 l O H 0 E N�R C SEE ATTACHED. --- - =ALT Q.EPARTMENT USE ON Y_ 7,� Application Accepted By Date S /`�Y C Area Destruction Inspection By Date U ` Employee ID# COMMENTS —l — ° PE Sc Received Amount Date Permit/ Invoice# WellID# Codes Info Cash Remitted Service Re uest# END 4308 WELL DESTRUCTION PERMIT 10/5107