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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468.3420 u~p qw• ,7 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED lJ� N JOB ADDRESS Anthony Ave.&Hobart Ave C[TY/ZIP Stockton,CA 95215 �r7 = CV Q CROSS STREET Adrienne Ave. APN PARCEL SIZE LAND USE APPLICATION# Z OWNER PG&E/Tommy Edward PHONE 661 330-2691 :aL J LL OWNER ADDREss2600 Camino Ramon CITY/STATE/ZIP San Ramon,CA 94583 z .O CONTRACTOR Cascade DFIIIInQ LLP PHONE 916-638-1169 rr-• "' CONTRACTOR ADDRESS 3000 Duluth Street CITY/STATE/ZIP West Sacramento,CA 95691 C-57 WELL DRILLING LICENSE NUMBER 938110 EXPIRATION DATE Sept.30th,2019 t 11i PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ® C-57 Well Drilling License Number 938110 Expiration Date 9/30/2019 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 E] Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) '�90 Adjacent property with contamination(Address) �® Known Soil/Water contaminants at adjacent property qY rJ EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom El Gravel Pack ❑ UncaSed ❑ Other Coke Breeze J04Q 9 Well Log copy attached ❑ Yes ® No Grout Seal ❑ No El Yes 90 ft below ground surface(bgs) Hole Diameter_ 8 inch*/ �V(RO 0//V Well Conductor Casing❑ Yes EI No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches y 0 pM Co N�. Well Casing Diameter 2 inches Total Depth 122 _ft Depth to Water ft Depth of Casing ft bgs �RTM�NT DESTRUCTION SPECIFICATION Sealing Material from 0 ftbgs to 122 ft bgs Filler Material from ft bgs to ft 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 Cemen g4/b bag/5-6 gal water) Sand Cement sack mix 17 gal water Bentonite Pellets Bentonite(20%solids durer Spec%solids % Name_ Specs on File Specs Submitted Placement Method Free Fall Other Seal Completion Complete with Mushroom Cap 5 ft 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 48/HOUR /ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE &- &"= TITLE VP Operations DATE 4/17/2019 PZENT USE ONLY Application Accepted By ADate Area Destruction Inspection By Date Employee COMMENTS PE SC Received Chec Amount Permit] Codes Info ash emitted Date Service Request# Invoice# Well ID# 19 1 EHD 43-08 r� ✓ !�- n� WELL DESTRUCTION PERMIT revised 4114118 v`(�G(�