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rR WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes Cj No SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTII DEPT 1858 East Hazeitorr Avenue-STOCKTON CA 95205-6232-(209)468-342D NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 4 YEAR FROM DATE ISSUED JOBADDREss 23851 Kasson Road c,Tyfz1P Tracy, CA 95304 m CROSSSTREET Mancuso Road APIN 239-090-04 PARCEL SIZE!--I LAND USE APPLICATION# c c OWNER PG&E PHONE s OWNERADDRESS 8180 Folsom Blvd CITYISTATEIZIP Sacramento, CA CONTRACTOR Gulf Shore Exploration PHONE 916-939-4117 CONTRACTOft AODREss 3362 Fitzgerald Rd CITYISTATFasp Rancho Cordova, CA 95682 X 0-57 WELL DRILLING UCENBENumnit 964224 EXPIRATIONDATS 8/31/2021 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CrryISTATEIZtP ❑ C57 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 Sherif-Coroner Explosives Application and Permit License Number Expiration Data California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Re�ST�mant Well [I Caved in ❑ Pit Well ® Inactive [I Test Hole Detected I Suspected Well Water Contaminant(sj�` A Adjacent property with contamination(AddressN/A Known Soil I Water contaminants at adjacent property N/A _ j EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased IN Other Unknown ! Well Log copy attached ❑ Yes jg No Grout Seal ❑ No ❑ Yes fl below ground surface(bgs) Hole Diameter Inches Well conductor casing IK Yes ❑ No Depth of Conductor Casing Unknown 9 bgs Diameter of Conductor Casing 12 Inches Wall casing Diameter 8 Inches Total Depth_168 ft Depth to Water 15 it Depth of Casing 11 bgs D€sTRVcrtoN 5P€ftFtCATIo\ Sealing Material from 168 R bgs to 0 ft bgs Filler Material from it bgs to ft bgs Well casing to be perforated by one of the following methods, from R bgs to N bgs ❑ Mills Knife Number of cuts ever/__ ff and I or ❑ Explosives q Detonating cord ❑ with projectiles every R ❑ without projectile ❑ Detonaling cord and boosters ❑ with projectiles every R ❑ without projectile [ ❑ Other Sealing Material X Neat Cement f941bbag/5-6gal waled Sand Cement sack mix 17 gal water BenionitePellets E Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted f Placement Method X Pumped Free Feil Other Seal Completion X Completewith Mushroom Cap 3 to 5 H bgs Complete to Existing Surface Pad I 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I 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 LAW I i MI UM 48 OUR DV CE NOTICE REQUIRED FOR INSPECTIONS i CONTRACTORS SIGNATOR TITLE y ?- DATE 1 I I I _I I l l -I I 1 1 _! t i l I I I I _. I I I .I I L.. I I I 1 t_ 1_ I___I 1_.I__ I 1 1._1.__1__1_ I I I I _I_._I_ 11 _:I.._. ®r• ®` � I { . ---I I I - I I _ I I I... r 18 I I II _I .,- __L.... -. 1 _1SIE L -97h 1CHE6 N}1�,P� _ I 1. ._. I I I ._I.-- ThR�NM co, I _I 1 1. 1 �_- V I I I (_ I .I I . .. . I fI I .... .1. I I .I .I . 1 . I . I 1 L �. . ...a l _III 1-1-1- { I { _ AR MENT USE ONLY �/ 9 Application Accepted By�-`, Data Area.?/,,., ,,`,,.....ftnsl Deslfucllon Inspection By Dale Orf ZI, Employee tD# COMMENTS �.6( 5; C S L d i 1) f! r A f.1 viell fie d "k • Ca Co n l h�/7I PE SC Received check#1 Amount Permlg ,nf Dae invoice# Well ION ode Info B Cash emoted ServlceRe nest# t�ILVt'� I I f' r I L I rof� EHD43-0 ��nl u1. ( �r Eu p¢rm/r v(Aer, •: CE 1 R OWf� I revis 4!4110 d��rek� 41.�r W Pd r+S bra h'LA-to I to e �^ `�71 I 1113 2— ;I c ar '+ rrr �►< �s i�u1 ar 9 � P Sordaw, �re�►�etder aM� �g c��y • � -tVvtir2 Oocc Per Milt (v>L(, l04 tiC� 6iS3)