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WELL DESTRUCTION PERMIT • 81, PVC PUBLIC WATER SYSTEM ❑Yes t No 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 s JOB ADDRESS 18389 McKinley Ave. CITY/ZIP Manteca 95337 CROSS STREET S.Yosemite Ave.. APN 241-400-29 PARCEL SIZE 1 5.QaND USE APPLICATION# C OWNER Yosemite-McKinley Three LLC c/o RB Environments/HONE 209-740-8205 OWNERADDRESs 4460 S. Hwy 99 Frontage Rd. CITY/STATEIZIP Stockton, CA 95215 CONTRACTOR Hennings Rrnc J]ri. linq ( n InC PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto CA 95356 XC-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2022 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP C-57 Well Drilling License Number 290813 Expiration Date 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 Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well [X 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 Cl Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes X No Grout Seal ❑ No ❑ Yes it 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 Diameter611 Steel inches Total Depthest. 15% Depth to Water ft Depth of Casing est.150 ft bgs DESTRUCTION SPECIFICATION Sealing Material from O ft bgs to est.150t bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft 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 ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets X Bentonite(20%solids) Manufacturer Spec%solids_% Name Quik Grout Specs on File Specs Submitted Placement Method XPumped 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 HO R ADVANCE NOT E EQU `'R SPECTIONS CONTRACTORS$IONA7URE TLE V•P• DATE Nov. 22, 221 I I I I I I I f I I j --- - - 1---- -- � 4 T 'ryCp �IJ - - DEPARTMENT USE ONLY S nf� Application Accepted By �-�� Date 12-10/L2 I Area Destruction Inspection B / + Data 11-.1(P Employee ID# COMMENTS i1.LI� J�h PE SC Received Chec Amount Date PermIV Invoice# Well ID# Codes Info Remitted Service Request# 4373 WSJ ISI EHD 43-08 WELL DESTRUCTION PERMIT 10/5107