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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes UNO 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 JOB ADDRESS 1357 Veteran St. CITY/ZIP Manteca,CA 95337 CROSS STREET S.of E.Woodward Ave. APN 224-710-62 PARCEL SIZE .18 LAND USE APPLICATION# OWNER VintageL.P. c/o ea on Transportation, Inc. PHONE 209-518-8789-Joe OWNERADDRESS P.O. Box 4433 CITYISTATE/ZIP Manteca, CA 95337 CONTRACTOR Hennings Bros milling Cn,Inc PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto. CA 95356 C-57 WELL DRILLING LICENSE NUMBER 2,90813 EXPIRATION DATE 5-31-22 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP IX C-57 Well Drilling License Number 290813 Expiration Dale 5-31-22 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 I Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil I Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes X 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- 8„ PVGnches Total Depth est 200t Depth to Water ft Depth of Casinge,St 200 It bgs DES IRC('I]ON SPE(I F'ICATION Sealing Material from O ft bgs tcest.2OO ft bgs Filler Material from ft bgs to ft bgs Well Casing to be perforated by one of the following methods: from It bgs to ft bgs ❑ Mills Knife Number of cuts every--ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every It ❑ without projectile ❑ Other_ Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets XBentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped X Free Fall Other Seal Completion Complete with Mushroom Cap 5 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 24 HOUR ADVANCE NOTICE REQU1I NSPECTIONS CONTRACTORS SIGNATURE b Thin. V.P. DATE 11-29-21 I I ( ;4y e� �� o �VF r Gln S nc 49 - - - o '?o h� ,R k U Co ?� - -- .. O F N M gRTM HT DEPARTMENT USE ONLY Application Accepted By Date �.� f Area �G l� L' ' "i• Destruction Inspection By n - - I Date �J� ' Employee ID# COMMENTS '50 11, Volk- Wed �zS PE SC Received Che Amount Date PermiU Invoice# Well ID# Codes Info Remitted Servlc, uest# 5. EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07