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r WELL DESTRUCTION PERMIT 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 JOB ADDRESS 225 Mosswood Ave CITY/ZIP Stockton,CA m CROSS STREET Odell Ave APN 16530405 PARCEL SIZE .16 LAND USE APPLICATION# A OWNER Pacific Gas and Electric PHONE 1800-468-4743 H 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 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 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 N Other Coke Breeze Well Log copy attached M 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 Diameter 1 Jnches Total Depth 200 it Depth to Water ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to 200 it bgs Filler Material Neat Cement from 0 It bgs to 200 It 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 DC Other Flush cover will be removed and hole will be overdrilled to 200'with 8.25".Materials will be removed Sealing Material a Cement(94 lb bag/5-6 gal we a Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manu acturer pec%solids_% Name Specs on File Specs Submitted Placement Method < um a Free Fail Other Seal Completion Complete With Mushroom Cap ft bgsomplete to Existing Surface Pa 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 �i---�— TITLE VP DATE 5-8-20 I I EENT Wet) MA - 12 2010 SANffJ0AO jN COUNTY EALTH D MENTAL PARTMENT DEPARTMENT USE ON Y l�LL Application Accepted By G Date S '2 0 2 D Area Destruction Inspection By Date Employee ID# COMME TSP I 14 C G. Jort Wei Y► wpoowc n 6f, n O� S lktaldT b PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info ash Remitted Service Re uest# %L7j161 U EHD 43-082 WELL DESTRUCTION PERMIT / revised 4/14118 6 833 f^ —