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WELL DESTRUCTION PERMIT # 11717 <br />PUBLIC WATER SYSTEM ❑ Yes ® No <br />SAN JOAOUIN 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 247 Airport Way <br />CITY/ZIP Manteca, 95337 <br />CROSS STREET West Ynsamita AVAn11P APN 19817017 <br />log <br />PARCEL SIZE acres LAND USE APPLICATION # <br />OWNER John Aretakis <br />PHONE 209-602-2759 <br />OWNER ADDRESS 565 S Austin Road <br />CITY/STATE/ZIP Manteca, CA 95337 <br />CONTRACTOR Cascade Drilling <br />PHONE (916) 638-1169 <br />CONTRACTOR ADDRESS 3000 Duluth Street <br />CITY/STATE/ZIP West Sacramento, CA 95691 <br />C-57 WELL DRILLING LICENSE NUMBER 936110 <br />EXPIRATION DATE 09/30/2019 <br />PERFORATION CONTRACTOR McMillan Well Services, LLC <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS McMillan Well Services, LLC <br />CITY/STATE/ZIP Bakerfield, CA 93312 <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />California Occupational Safety Health - Blaster <br />License Number 9201 Expiration Date 4/5/2021 <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ® Inactive ❑ Test Hole <br />Detected / Suspected Well Water Contaminant(s) MTBE <br />Adjacent property with contamination (Address) Unknown <br />Known Soil / Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes M No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes M No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 6 inch inches Total Depth 170 ft Depth to Water Unknovnt ft Depth of Casing 170 ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from Total Depth ft bgs to 0 ft bgs Filler Material <br />None from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />from 0 ft bgs to 170 ft bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />H Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />M Detonating cord and boosters 13 with projectiles every <br />10 ft ❑ without projectile <br />❑ Other <br />Sealing Material ViNeat Cement (94 Ib bag /5-6 gal wafer) Sand Cement sack mix /7 gal water Bentonite Pellets <br />Bentonite (20% sol' urer Spec % solids_% Name <br />Specs on File Specs Submitted <br />Placement Method Pumped Free Fall <br />Other <br />Seal Completion CompFeTe—v,-nffi-M—ush room Cap ft bgs Co plete 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 RE UIRED FOR INSPECTIONS <br />CONTRACTORS SIGNA <br />Application Accepted By _ <br />Destruction Inspe n By <br />COMMENTS _4CM <br />■�� �=i��h ItIrV,/:�7I� X13 J�����n� • <br />A TMENT USE 4 <br />Date <br />i . Date <br />Area <br />Employee ID# <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info ash emitted Date Se Permit/est Re uest # Invoice # Well ID# <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />revised 4/14/18 <br />