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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [g 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 m JOB ADDRESS 232 Milgeo Ave. CITY/ZIP Ripon 95366 CROSS STREET E. of N. Stockton Rd. APN 261-200-05 PARCEL SIZE .41 LAND USE APPLICATION# OWNER-Henry Vander Bosch c/o Nicholas Viss Construction PHONE 499-2347 OWNERADDRESS 332 Otllet St. CITY/STATE/ZIP Ripon, CA 95366 CONTRACTOR Henninis Brns nrillinqfb , Inc PHONE 545-1185 CONTRACTOR ADDRESS 1930 iadi 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 tX 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 [X Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent propertywith contamination(Address) Known Soil/Water contaminants at adjacent property 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_5� Sleel inches Total Depth est._10()t Depth to Water___ ft Depth of Casing est-._1.00ft bgs DESTRUCTION SPECIFICATION The Bump is still in the well. Sealing Material from 3 ft bgs to P.St 1 �nbgs Filler Mated I from ft bgs to _it bgs Well casing to be perforated by one of the following methods: ____ from ft bgs to ft bgs ❑ Mills Knife Number of cuts every 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/b bag/5-6 gal water) Sand Cement 10.3 sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method X Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 3 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 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 ADkIANCE NOTICE R 0 FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE V.P. DATE 11-20-19 I - _ SEE ATTCHED MAP _ jV,Z 2019 1- - - --- -- - - 1 H N oho )N COO/V EAL7H p AR7-M - SENT LIEPARTMENT USE ON 'Y Application Accepted By Date L7 Area Destruction Inspection By Date Employee ID# Y COMMENTS , PE SC Received Amount Date permit] Invoice# Well ID# Codes Info ash Remitted I Service Re uest# Yui 1-) )I T777- EHD 43-08 WELL DESTRUCTION PERMIT 1015/07