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WELL DESTRUCTION PERMIT <br />C1609 Destruction PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRES# E 5th St CITY/Zip Stockton, 95203 <br />CROSS STREET S. American APN ROW PARCEL SIZE _LAND USE APPLICATION # <br />OWNER PG&E f)aw 16 PHONE <br />OWNER ADDRESS 3965 Occidental Road CITYISTATEIZIP Santa Rosa, CA 95401 <br />CONTRACTOR Gregory Drilling PHONE 530-565-6289 <br />CONTRACTOR ADDRESS 14112 452nd Ave SE CITY/STATEIZIP North Bend, WA 98045 <br />C-57 WELL DRILLING LICENSE NUMBER 1007649 EXPIRATION DATE 1/31/23 <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP <br />N C-57 Well Drilling License Number 1007649 Expiration Date 1-31-23 <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expiration Date <br />California Occupational Safety Health - Blaster License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well N Inactive ❑ Test Hole <br />Detected / Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased N Other <br />Well Log copy attached ❑ Yes 0 No Grout Seal ❑ No IN Yes 90 it below ground surface (bgs) Hole Diameter 6 inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 1 inches Total Depth 120 ft Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to 120 ft bgs Filler Material Neat Cement from 0 It bgs to 120 ft bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ With projectiles every ft ❑ Without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every ft ❑ Without projectile <br />® Othsr Well will be overdrilled with 7.25" Sonic casing and Growled via trimmie pipe from the bottom up <br />Sealing Material I Neat Cement (941b bag/5-6 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 Pum ed Free Fall Other <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 />CONTRACTORS SIGNATURE � TITLE VP DATE 7-9-23 <br />Application Accepted By_ <br />Destruction Inspection By <br />COMMENTS <br /><73- , <br />DEPARTMENT USE ONLY <br />R <br />YMFN <br />SqN JUL <br />19 2021 <br />IJOA f HEATH p <br />Li/tv <br />y <br />ART MENT <br />Sf1ck4V0 <br />_PE I SC I Received I Check#/ Amount I bate, PermiU - y <br />bate--, _ _ _ __ _ _ Invoice # Well 1D# <br />EHD 43411 W . I -2-09 4-,S2SI2 WELL DESTRUCTION PERMIT <br />revised 4/14/18 <br />