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r <br />WELL DESTRUCTION PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />rn <br />Jos ADDRESe Swanson Rd & W Yosemite Ave, (GPS: 37.797363,-121.2599485) CITYILP Manteca, CA 95337 1I M <br />CROSS STREET W YOSEMITE RD APN I C71V , 17 O 1 ^ PARCEL SIZE LAND USE APPLICATION # <br />OWNER CITY OF MANTECA PHONE <br />OWNER ADDRESS W 95337, 1001 W Center St CRY/STATEIZIP MANTECA, CA 95337 <br />CONTRACTOR CORRPRO COMPANIES INC., PHONE 510-509-4993 <br />CONTRACTOR ADDRESS 26250 BARRINGTON CT CITY/STATE/ZIP HAYWRAD, CA 94545 <br />C-57 WELL DRILLING LICENSE NUMBER 0764878 EXPIRATION DATE 06/30/2021 <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />S/ C-57 Well Drilling <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />CHP Hazardous Material Transportation for Explosives <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />California Occupational Safety Health - Blaster <br />_CITY/STATEIZIP <br />License Number C 764878 <br />License Number <br />License Number <br />License Number <br />License Number <br />Expiration Date <br />Expiration Date <br />Expiration Date <br />Expiration Date <br />Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry N1 Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole <br />Detected / Suspected Well Water Contaminant(s) <br />CA 9533 <br />Adjacent property with contamination (Address) Swanson Manteca, <br />Known Soil / Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Park ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br />Sealing Material from ft bgs to ft bgs Filler Material_ <br />Well casing to be perforated by one of the following methods: <br />❑ Mills Knife Number of cuts every ft and I or _ <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />❑ Detonating cord and boosters ❑ with projectiles every <br />from ft bgs to ft bgs <br />from ft bgs to ft bgs <br />ft ❑ without projectile <br />ft ❑ without projectile <br />❑ Otfrof <br />Sealing Material VNeat Cement (94 lb bag 15-6 gal water) Sand Cement sack mix / 7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids % Name Specs on File Specs Submitted <br />Placement Method Pumped Free Fall Other ROUT SEALING -WELL DEPTH 120' <br />Seal Completion Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />DEPARTMENT USE ONLY LL <br />Application Accepted By �Date 3 aS % Area c Y'4C <br />Destruction Inspection By 7"`�' Date Employee ID# AC <br />COMMENTS �� G If 6? 17$ SFJ CrY1SJI1 -- APAJ /Vy70'Vy <br />PE SC Received Check#/ Amount ate Permit/ Invoice # Well ID# <br />Codes Info Cash Remitted S ice Request # <br />373 iC I rSw 1 <br />EHD 43-08 / 2Z.� , / WELL DESTRUCTION PERMIT <br />revised 4/14/18 �/ � <br />v <br />"AlINT <br />Ep <br />5 2021 <br />4EN°LINTY <br />AL <br />4RTMENT <br />