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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 Joe ADDRESS 0 -E Morada Ln,Stockton,CA 95212(WORKING RIGHT OF WAY) CITY/ZIPStockton,CA 95212 m CROSS STREET NMADELINE DR APN 0351303 ARCELSIZEd-61 LAND USE APPLICATION# OWNER CITY OF STOCKTON PHONE Ian OWNER ADDRESS CITY HALL,425 N,EL DORADO ST CITY/STATE/ZIP STOCKTON,CA 95202 CONTRACTOR CORRPRO COMPANIES INC., PHONE 510-509-4993 CONTRACTOR ADDRESS 262SC BARRINGTON CT CITY/STATE21P HAYWARD,CA 94545 V C-57 WELL DRILLING LICENSE NUMBER C764878 EXPIRATION DATE 06/30/2021 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/7JP S/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 ❑ Dry &IReplacement 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 ❑ Gravel Pack ❑ Uncased ❑ Other 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 Well Casing Diameter inches Total Depth ft Depth to Water It Depth of Casing It bgs DESTRUCTION SPECIFICATION ��-., Seating Material from d ft bgs to)A 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 ❑ 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 ❑ tMha Sealing Material Neat Cement(94 Ib bag 15-6 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 Pumped Free Fall Other 120'well-2"VENT PIPE 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 /�/iris,-'�. 1 TITLE OPERATIONS MANAGER DATE 01/18/2021 i I �h I. PAY T _ . -- ................ - -- 021 SAN Jt)AQUIW_- UNTY FNVIPCNMEIITAL I I -0 MENT I DEPARTMENT USE ONLY (� Application Accepted ey � Date 5" v? Area / Destruction Inspection By Date 2 Zr7L Employee ID# DA / COMMENTS t7u<, 7 j� fJtf`t N arC iGJ �.- I- S iN. rD d PE Sc Received Amount Date Permit/ Invoice# Well INCodes Info Remitted Service Re uest# 73 D 2 / S 1 EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18