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WELL DESTRUCTION PERMIT f OC-GC� 0k'CI D'�-5%2uCTwtil 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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED y JOB ADDRESS Northwest Corner of Brandt Rd and Skaggs Ranch RD CITYZF�ZCi Linden,CA 95236 CROSS STREET Skaggs Ranch Rd APN 023-170-08 PARCEL SIZE 363 LAND USE APPLICATION# OWNER Pacific Gas and Electric PHONE 1800-468-4743 a OWNER ADDRESS PO Box 997300 CITY/STATE/ZIP Sacramento,CA 95899 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 th-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry IJ 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 I'9 Yes ❑ No Grout Seal ❑ \o ❑ Yes __ it 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 200_ If Depth to Water ft Depth of Casing ft bgs D4 S1 R1 CFIOS SPI'.cIFICATION Sealing Material from 0 ft bgs to 200 It bgs Filler Material Neat Cement from 0 ft bgs to 200 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 IN Other ':Veil will be overdnlled with 8 25"Sonic Casing All Materials will be removed.Trimmie Neat cement from 200'-Surface Sealing Material Neat Cement(94 lb bag/6-6 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE � j TITLE VP DATE 3-28-20 RF yMENT CF�V�D <` SAN PR 46Z020 �,�L'L � H FN IR QUIN C pART��NTY _ DEPARTMENT USE 04N' N L Y Application Accepted By �� !• Date L/ DF' Z13�c� Area C`T Destruction Inspection By 1 Date Employee ID# S K COMMENTS Lr41 f L66' i — PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info Remitted Service Request# 3.-J s Z� EHD 4308 WELL DESTRUCTION PERMIT revised 4/14/18