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WELL DESTRUCTION PERMIT PU13UC WATER SYSTEM ❑Yes ❑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 Adjacent to 12988 Neugebauer Road,Stockton,CA(GPS:37.978947.-121.472471722 CITY/ZIP STOCKTON,CA 95206 m CROSS STREET MCDONALD RIVER BRIDGE APN 13102025PARCEL SIZE LAND USE APPLICATION# c v OWNER CITY OF STOCKTON PHONE .n OWNER ADDRESS CITY HALL,425 N.EL DORADO ST CITY/STATE/ZIP STOCKTON,CA 95206 CONTRACTOR UNDERGROUND CONTRUCTION PHONE CONTRACTOR ADDRESS 5145 INDUSTRIAL WAY, CITY/STATE/ZIP BENICIA,CA,94510 C-57 WELL DRILLING LICENSE NUMBER 764878 EXPIRATION DATE PERFORATION CONTRACTOR CORRPRO COMPANIES PHONE 502-509-3050 PERFORATION CONTRACTOR ADDRESS 2625C BARRINGTON COURT CITYISTATE/ZIP HAYWARD,CA 94545 ❑ C-57 Well Drilling License Number 764878 Expiration Date Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Dale 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 ❑ 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 ❑ 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 Diameterinches Total Depth_ l ft Depth to Water__ ft Depth of Casing 0 It bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to._�ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods, F 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 It ❑ without projectile ❑ Other Sealing MaterialCement(94 16 bag/5-6 gal water Sand Cement sack mix/7 gal water Bentonite Pellets .5 Bentonite(20%solids) ufacturer Spec%solids_% Name Specs on File Specs Submitted 7 Placement Method Pumpe Free Fall Other M (JP firkl-nW/e J 9(� Y Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad C� 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 I \ WORKERS COMPENSATION LAWS. t[ zsho 2 J MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS f CONTRACTORS SIGNATURE t��✓w S� TITLE CM DATE 1/24/2020 , 711 f #44-1 1- 1 -14-J fl qQv� ?020 4T RO/V N CO t �R N M� ry � FNT r DEPARTMENT USE ONLY /Application �]� Application Accepted By Date /Z21/ L 0 ZD Are. Destruction Inspection By Date !i U ZD Employee ID# COMMENTS + 10 . li-IR -'- 1 ��L' �"` � � '-1 nYli- PE Sc Received Check#/ Amount PermiU Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 1 J� r EHD WELL DESTRUCTION PERMIT revisedd 411 4/14/18