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WELL DESTRUCTION PERMIT #17663 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 177 Airport Way CITY/Zip Manteca 95337 CROSS STREET West Yosemite Ave APN 19817021 PARCEL SIZE / LAND USE APPLICATION# OWNER Guadalupe Anaya PHONE 209-239-1918;209-482-1375 y OWNER ADDRESS 177 Airport Way CITY/STATE/Zlp Manteca 95337 CONTRACTOR Cascade Drilling PHONE(916)638-1169 CONTRACTOR ADDRESS 3000 Duluth Street CITY/STATE/Zlp 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 Expiration Date 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 1' No Grout Seat ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes V No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter unkno I inches Total Depth unknown ft Depth to Water unknown ft Depth of Casing unknown ft bgs DESTRUCTION SPECIFICATIO 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 total depth ft bgs ❑ Mills Knife Number of cuts every ft and/or Id Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile W Detonating cord and boosters q 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%solids Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pum a Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Complet to Existing Surface= 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 488�,,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS {IA";1 CONTRACTORS SIGNATURE Z1 TITLE VP Operation DATE 03/29/2019 PA - - -- + -r- �- - ; - -- ie/v - - l� s-vv J01G EN GUlN k�CT SEP F��NIY Af?Tlv60 I P RTMENT USE O LY Application Accepted By Date Area Destruction Inspect; By GL{�I tai ate Employee ID# I,atl- COMMENTS PE SC Received Check#/ Amount Permit/ Codes I fo B ash emitted Date Service Re uest# Invoice# Well ID# V- 0 EHD 43-08 bw / WELL DESTRUCTION PERMIT revised 4/14118 �r�` /�