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-e WELL DESTRUCTION PERMIT PUBUC WATER SYSTEM P Yes 0 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East HazeIton Avenue -STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNJ ABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR V . FROM DATE ISSUED JOB ADDRX-19,1-29•DAVIS RD (RIGHT OF WAY) a &sr 8.7a 3 crry,,,p STOCKTON CA 95209 CROSS STREET THORNTON RD APN 0 7a 92 0 ic (fity,) PARCEL SIZE • V LAND USE APPLICATION # CITY OF STOCKTON OWNER PHONE CITY HALL, 425 N, EL DORADO ST STOCKTON, CA 95202 OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR CORRPRO COMPANIES INC., 510-509-4993 PHONE CONTRACTOR ADDRESS 2625C BARRINGTON CT CITY/STATE/ZIP HAYWRAD, CA 94545 V C-57 WELL DRILLING LICENSE NUMBER C764878 EXPIRATION DATE 06/30/2021 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 6/ C-57 Well Drilling License Number C 764878 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 0 Dry Replacement Well 0 Caved In 0 Pit Well 0 Inactive 0 Test Hole Detected / Suspected Well Water Contaminant(s) 1440 Ponce De Leon Ave, Stockton, CA 95209 Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Log copy attached 0 Yes 0 No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing 0 Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth Igo ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft 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 0 Mills Knife Number of cuts every ft and / or 0 Explosives 0 Detonating cord 0 with projectiles every ft 0 without projectile 0 Detonating cord and boosters 0 with projectiles every ft 0 without projectile 00th., . Sealing Material ) Neat Cement (94 lb bag / 5-6 gal water) Sand Cement sack mix / 7 gal water Bentonite Pellets Bentonite (2(.i% solids) Manufacturer Spec % solids % Name Soecs on File Specs Submitted Placement Method Pumped Free Fall Other_ Seal Completion Complete with Mushroom Cap 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE OPERATIONS MANAGER DATE 01/04/2020 DEPARTMENT USE ONLY Application Accepted By - Date Area 3h4DC WO 1/ Destruction Inspection By (,) Date 13:1 I Employee ID# pott 90MMENTS pe tea r I IS a hol neki cre, /41-0,/ frotiocliD77 Well m seam evt. pe Nea vd ell t. heier C a frAY PM+ r ) , PE Codes SC Info Received Check#/ ...Cash Amount JRemittecl, Da Permit/ Service Reguegtft Invoice # Well ID# t1373 IL ) dip_ ih nA__, 4 i C/5 I 111 le ))1 /14100L1(OUr0 EHD 43-08 revised 4/14/18 017 MI'? WELL DESTRUCTION PERMIT