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WELL DESTRUCTION PERMIT #17950 <br /> 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 ADDRESS 134 Airport Way CITY/ZIP Manteca 95337 <br /> n <br /> CROSS STREET West Yosemite Ave APN 20014012 PARCEL SIZE acres LAND USE APPLICATION# O <br /> a <br /> OWNER Zoe Haworth PHONE 209-605-4915 <br /> OWNER ADDRESS PO Box 579533 CITYISTATE/ZIP Modesto 95357 <br /> CONTRACTOR Cascade Drilling PHONE(916)638-1169 <br /> CONTRACTOR ADDRESS 3000 Duluth Street CITY/STATE/ZIP West Sacramento,CA 95691 <br /> C-57 WELL DRILLING LICENSE NUMBER 938110 EXPIRATION DATE 09/30/2019 <br /> PERFORATION CONTRACTOR McMillan Well Services,LLC PHONE <br /> PERFORATION CONTRACTOR ADDRESS 12302 Andes Ave CITY/STATE/ZIP Bakerfield,CA 93312 <br /> ❑ C-57 Well Drilling License Number Expiration Date <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 9201 Expiration Date 4/5/2021 <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well M Inactive ❑ Test Hole <br /> A Detected/Suspected Well Water Contaminant(s) MTBE <br /> Adjacent property with contamination(Address) Olt <br /> Known Soil/Water contaminants at adjacent property <br /> �1 EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> Well Log copy attached ❑ Yes ® No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes 13t No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter 6 inches Total Depth 59 ft Depth to Water Unknown ft Depth of Casing 59 ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from Total Depth ft bgs to 0 ft bgs Filler Material None from ft bgs to ft bgs <br /> Well casing to be perforated by one of the following methods: from 0 It bgs to 59 ft bgs y <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> k7 Explosives❑ Detonating cord ❑ With projectiles every ft ❑ without projectile <br /> M Detonating cord and boosters 0 With projectiles every 10 ft ❑ without projectile <br /> ❑ O&Ar <br /> Sealing Material eat Cement(94 Ib 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 Pumped Free Fall Other <br /> Seal Completion Complete with Mushroom Cap ft bgs Complete Existing buriace FED <br /> I HEREBY CERTIFY THAT 1 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 /> MINI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CONTRACTORS SIGNATURE TITLE VP Operations DATE 03/29/2019 <br /> ' i <br /> co <br /> - I i 4f ONIf � <br /> A MENT USEO L <br /> Application Accepted By Date Area <br /> Destruction Ins pe By Date Employee D# <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ AWELL <br /> 11 <br /> Codes Info B Cash Remit ed a ice Re uest# <br /> to I •� OFOOMaIn JL <br /> EHsed 4/1 ( �` �!L�i <br /> revised 4/14/18 <br />