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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1866 East Hazelton Avenue-.STOCKTON CA 95205.6232 - (209) 466-3420 NON.RFFI INnARI F PFRMIT rAl I IIAQ1 Q5'i.7AQ7 FAR INCPFrTIr1NS FYPIRFS 1 YFAR FRnM DATE ISSItEn JOB ADDREP S Whiskey Slough Rd & S Trapper Rd, Stockton (GPS: 37.926829,-121.430088) CITy21p CA 95206 CROSS STREET Trapper Rd APN O h atr PARCEL SIZE LAND USE APPLICATION # OWNER CITY OF STOCKfON PHONE OWNER ADDRESS CITY HALL, 425 N, EL DORADO ST CITY/STATE2IP STOCKTON, CA 95202 CONTRACTOR CORRPRO COMPANIES INC., PHONE 510-509-4993 CONTRACTOR ADDRESS 2625C BARRINGTON CT CITY/STATE/LP HAYWARD, CA 94545 J C-57 WELL DRILLING LICENSE NUMBER 0764878 EXPIRATION DATE 06/30/2021 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEMP C-57 Well Drilling License Number I 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 4Rplacement 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 It bgs Diameter of Conductor Casing inches Well Casing Diameter inches Total Depth ft Depth to Water It Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 1610 It bgs to O It bgs Filler Material from ft bgs to It bgs Well casing to be perforated by one of the following methods: from ft bgs to It bgs ❑ Mills Knife Number of cuts every ft and / or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ ottter Sealing Material V Neat Cement (94 lb bag / 5-6 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 GROUT SEALED TO TOP Seal Completion Complete with Mushroom Cap 3-- 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 �r'��✓ ODCRATIV)nIC KAAAIArPP na/nsnrnl y e�y b d DEPARTMENT USE yO LY Application Accepted By Gam— /"��+ ' Date T WIZ Destruction Inspe ion By�IDate Z romMF:NTR (�Z4 01 C 10-"- -h-C Mim v;Oe I Iri is.7�'/b✓/ Fp 4?021 044' �Nry 4 174' - Area -31'ef, 1!9 `yn,37,11 Employee ID# V PE Sc Received Check#/ Amount Date Permit/ Invoice# WellID# Codes Info Cash Remitted Aervice Re uest# 373 S9- 41S— 44 EHD 43.06 WELL DESTRUCTION PERMIT revised 4/14/18 12 3'f 3a77�