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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 y JOB ADDRESS 2092 Pillsbury Rd. cITYrzIP Manteca 95337 CROSS STREET S. OI1WOOdWar AVe. APN 224-690-20 PARCEL SIZE'` ` IND USE APPLICATION# OWNER Atherton Homes G bAID PHONE 775-420-8193-Tim OWNER ADDRESS 1314 Mono St. d CITY/STATE/ZIP Manteca, CA 95337 CONTRACTOR HannIn9S RrnS- Drlllin9 Cay Inc- 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/STATEILP EX 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 EX Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom Gravel Pack ❑ Uncased ❑ Other Well Log copy attached IX Yes ❑ No Grout Seat ❑ No CX Yes 5()_R below ground surface(bgs) Hole Diameter 20e inches Well Conductor Casing❑ Yes X No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 12 __ inches Total Depth _1.5q ft Depth to Water __- - - It Depth of Casing 159 ft bgs DESTRU(TION SPECIFICATION Sealing Material from _D_ft bgs to 159 ft bgs Filler Material _ _ from ft bgs to _ft bgs Well casing to be perforated by one of the following methods: from It 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 Ib 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 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. MINIMUM 24 HOUR,ADVANCE NOTICE PT= U E OR INSPECTIONS Nov.ONTRACTORS SIGNATURE N TITLE V-P- DATE 12,2019 , I iI I _ SEE ATTACHED —j — — — SAN ) .{ 2019 -hE,gCTy�N)FN'JAI I OFp TAC I I — 1 I I I I MENT USE ONY C, Application Accepted By Date 3 Area Destruction Inspection By Date Employee ID# %COMMENTS PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Remitted Service Re uest# EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07