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4 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 2 6 9 01 Hansen Road(See Map) clTYrcIP Tracy,CA 95377 m CROSS STREET None 1 SSW O APN 2 09-110-100-000 PARCEL SIZE 15.38 LAND USE APPLICATION# OWNER Costco Wholesale PHONE (425)313-6052 OWNER ADDRESS 999 Lake Drive CITY/STATE/ZIP Issaquah,WA 9 802 7 CONTRACTOR V&W Drilling PHONE 209-469-7700 CONTRACTOR ADDRESS 3806 Duck Creek Drive CITY/STATE/ZIP Stockton,CA X C-57 WELL DRILLING LICENSE NUMBER 720904 EXPIRATION DATE April 30,2022 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 M Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) NA Adjacent property with contamination(Address) NA Known Soil/Water contaminants at adjacent property NA EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ® Other found well-no information Well Log copy attached ❑ 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 Wel(Casing Diameter 6 inches Total Depth 15 It Depth to Water 13(perched)ft Depth of Casing UNK ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 It bgs to 15 It bgs Filler Material from ft bgs to ft 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 I or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ Without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ® ottw overdrill to 15' bg Sealing Material 4 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 Spars on File Specs Submitted Placement Method Pumped Free Fall X Other- tremmie grout Seal Completion )(Complete With Mushroom Cap 3 ft bgs Complete to Existing 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. I 8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE Staff Professional II DATE 11/16/2020 I I I PA Y FN ED s � ? -�- � ?020 AN J0 /N NA/7-ANTy C - TMENT DEPARTMENT USE ON Y Application Accepted By Date j" Area / Destruction Inspection B Date %% l 2-y 1%,b!2,a Employee ID# GOM,7ENTS Spoke w0l, V /)a &W-S JM A.11'%120 Will by CAMCA6/11l/ op��i h nc ULA[ U11t-Z)M P6fQ PE SC Received Check#/ Amount Date Permit' Invoice# Well ID# Codes Info B Ca Remitted Se Ic Request# y373 61S EHD WELL DESTRUCTION PERMIT revisedd 4/1 4/14/18 y