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WELL DESTRUCTION PERMIT DC-GBO145 Destruction PUBLIC 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 INSPECTIOr! EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 435 N Walnut Ave CITY21P Manteca,CA 95336 CROSS STREET Skaggs Ranch Rd APN 21759024 PARCEL SIZE .44 LAND USE APPLICATION# cl OWNER Pacific Gas and Electric (Walther Tigerino) PHONE 209-857-0181 OWNER ADDRESS 12840 Bill Clark Way CITY/STATE/ZIP Auburn,CA 95602 CONTRACTOR Gregory Drilling,Inc PHONE 425-869-2372 CONTRACTOR ADDRESS 14112 452nd Ave SE CITY/STATE/ZIP North Bend,WA 98045 C-57 WELL DRILLING LICENSE NUMBER 1007649 EXPIRATION DATE 1-31-2021 PERFORATION CONTRACTOR NA PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 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 Sheriff-Coroner Explosives Application and Permit License Number Expiration Date California Occupational Safety Heal in-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry Itn 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 K Yes ❑ No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter 8" inches Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter_ 2 inches Total Depth __ 1.20 ft Depth to Water ft Depth of Casing 120 ft bgs DES I RtCI]ON SPECIFU A 1107, Sealing Material from 0 It bgs to 120 It bgs Filler Material Neat Cement from 0 ft bgs to 120 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 It ❑ without projectile ❑ Detonating cord and boosters ❑ With projectiles every ft ❑ without projectile M Other e11 viii be overdnllad with 2 25"Sonic Casing All Materials will be removed.Trimmie Neat cement from 120'-Surface Sealing Material Neat Cement(94 lb beg/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Asphalt Hot patch Seal Completion Complete with Mushroom Cap 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. n so uf}i. a . rn,n"-)r_ NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE � TITLE VP DATE 3-28-20 R CIVIENr /V I AP� 06 1020 SAN HEAJOq O/N C LTH NMENTq NTY EPgRTMENT � DEPARTMENT USE ONLY Application Accepted By . * Date y/0 E/7Z zo Area r�G'i^jeCC. Destruction Inspection By X i,'�I!j.G�:LI �l —{,F.�,.��1/ Date G- 7Employee ID# ✓� COMMENTS PE SC Received Chec Amount Date Permit/ Invoice# WeII1D# Codes Info B s Remitted Service Request# 7 61 3 5 zc �`� (2 EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18