WP0039723 - Laserfiche WebLink

Home Browse Search

WELL DESTRUCTION PERMIT #17899 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 JOB ADDRESS 153 AirportWay CITY/ZIP Manteca 95337 CROSS STREET West Yosemite Ave APN 19817022 PARCEL SIZE LAND USE APPLICATION# OWNER Dawn Forry PHONE 209-483-8187 H OWNER ADDRESS 17144 Nile River Drive CITY/STATE/ZIP Sonora,CA 95370 CONTRACTOR Cascade Drilling PHONE(916)638-1169 CONTRACTOR ADDRESS 3000 Duluth Street CITY/STATE/ZIP 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/ZIP 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 California Occupational Safety Health-Blaster License Number 9201 Expiration Date 4/5/2021 REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well M 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 13; No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes IX No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter U pknoWn inches Total Depth Unknowri t Depth to Water Unknown It Depth of Casing Unknown ft bgs ge 13 40 DESTRUCTION SPECIFICATMNU Sealing Material from Total Deodlft bgs to 0 It bgs Filler Material None from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from 0 It bgs to total depth It bgs ❑ Mills Knife Number of cuts everyft and/or IX Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ® Detonating cord and boosters EV with projectiles every 10 ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%soll&L Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method I Pumped I Free Fall Other Seal Completion Complete with Mushroom Cap It bgs Complete ItExisting 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. M UM,8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE / ll TITLE VP Operations DATE 03/29/2019 ✓U 1 y ✓o 2014 �Tti�F, R�U-------------- N� PQ MENT USE ONLY Application Accepted By Date Area Afery Ir Destruction Inspe 'on B Date Employee ID# COMMENTS PESC Received Check#/ Amount PermiU Codes Info B,, 9ash Remitted Date Service Re uest# Invoice# Well ID# levV .f EHD 4308 //S/ WELL DESTRUCTION PERMIT revised 4114118 CCCJJJ !!!