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WELL DESTRUCTION PERMIT #17904 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 v. Joe ADDRESS 154 AirportWay CITYIZIP Manteca 95337 CROSS STREET APN — I YV l O PARCEL SIZE- C'LAND USE APPLICATION# C OWNER Luis Padilla PHONE 209-447-7559 y OWNER ADDRESS 15111 Hollyhock Court CITY/STATE/ZIP Lathrop,Ca 95330 CONTRACTOR Cascade Drilling PHONE(916)638-1169 CONTRACTOR ADDRESS Cascade Drilling CITY/STATE/LP West Sacramento,CA 95691 C-57 WELL DRILLING LICENSE NUMBER 938110 EXPIRATION DATE 09/30/2019 PERFORATION CONTRACTOR McMillan Well Services,LLC PHONE PERFORATION CONTRACTOR ADDRESS 12302 Andes Ave CITY/STATE/Zlp Bakerfield,CA 93312 ❑ 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 Califomia Occupational Safety Health-Blaster License Number 9201 Expiration Date 4/5/2021 REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ® Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s)MTBE 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 19 No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes IZ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 5.5 inches Total Depth 69.6 It Depth to Water Unknown ft Depth of Casing 65 It bgs DESTRUCTION SPECIFICATION Sealing Material from total depth ft bgs to 0 ft bgs Filler Material none from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from 0 ft bgs to 69.6 ft bgs ❑ Mills Knife Number of cuts every ft and/or- 9 nd/ord Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile m Detonating cord and boosters ® with projectiles every 10 ft ❑ without projectile ❑ Other Sealing Material V Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids ufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method rPumpedl Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complete ExistingSurface 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. I M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE r/F/Z= TITLE VP Operations DATE 03/29/2019 y4f _ _ - _ �'V //AAgg —0 LoOlCo pqq��<N� P. TMENT USE O L Application Accepted B Date d9' Area Destruction Inspe n By DateUlf Employee ID# COMMENTS IN LZrr PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info BCash Remitted Service Re uest# EHD 43-08 /" �9i y WELL DESTRUCTION PERMIT revised 4/14/18