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WELL DESTRUCTION PERMIT #11737 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 <n JOB ADDRESS 225 Airport Way CITY/ZIP Manteca 95337 CROSS STREET West Yosemite Ave APN 19817018 PARCEL SIZE -1-1 LAND USE APPLICATION# c OWNER David Newkirk PHONE 209-239-2012 OWNER ADDRESS 225 Airport CITY/STATE/ZIP Manteca 95337 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 CITYISTATE/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 ❑ 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 W Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes IX No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes [X No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 6 inches Total Depth 55 ft Depth to Water Unknown ft Depth of Casing 55 _ ft 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 55 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 10 ft ❑ without projectile ❑ Other Sealing Material /Neat Cement(94 lb bag/5-6 gal wafer) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solidsManufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method Pum ed Free Fall Other Seal Completion Complete wit ushroom Cap ft bgs Complete to Existinga 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. MINIMU10 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE VP Operations DATE 03/29/2019 ' i I --- sw Jo 19 2419 - - -'- -- NF'9C7y NME,y°�NTy t H� P.A TMENT USE ONL Application Accepted By Datek;lltl�q Area Destruction Inspect n By Date Employee ID# COMMENTS PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# des Info ash Remitted Se ice Request# EHD 43-08 • �C�J!� /[�L WELL DESTRUCTION PERMIT revised 4114118