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r <br />WELL DESTRUCTION PERMIT <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-RiFrimnARI F PFRMIT COI I l)AQI Q53_7AQ7 Fn* IMRPPCTInMH FYPIRFS I VFAR FRnM nATF IsclIFn <br />JOB ADDRESS F-8"460 W. Grant Line Road <br />CITy1ZIp Tracy, CA 95376 <br />CROSS STREET Bessie Avenue APN N/O 233-030-18 !!f.'r <br />PARCEL SIZE ' LAND USE APPLICATION # <br />OWNER City of Tracy <br />PHONE 209-831-6000 <br />OWNER ADDRESS 333 Civic Center Plaza, <br />CITY/STATE/Zip Tracy, CA 95376 <br />CONTRACTOR American Construction and Supply, Inc. <br />PHONE 415-927-2024 <br />CONTRACTOR ADDRESS 45 San Clemente Dr., Suite A-100 <br />CITY/STATE/ZIP Corte Madera, CA 94925 <br />C-57 WELL DRILLING LICENSE NUMBER 310599 <br />EXPIRATION DATE 03/31/2023 <br />PERFORATION CONTRACTOR American Construction and Supply, Inc. <br />PHONE 415-927-2024 <br />PERFORATION CONTRACTOR ADDRESS 45 San Clemente Dr., Suite A-100 <br />CITY/STATE21P Corte Madera, CA 94925 <br />® C-57 Well Drilling <br />License Number 310599 Expiration Date 03/31/2023 <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 Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ® Inactive ❑ Test Hole <br />Detected / Suspected Well Water Contaminant(s) N/A <br />pp <br />Adjacent property with contamination (Address) N/A v. <br />.. IY Y I <br />Known Soil / Water contaminants at adjacent property N/A r����' <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter _ inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter inches Total Depth ft Depth to Water It Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from /aa ft bgs to 0 It bgs Filler Material <br />from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods, <br />from It bgs to It bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ Without projectile <br />❑ lMfler <br />Sealing Material I Neat Cement (941b bag/ 5-6 gal water)] Sand Cement sack mix /7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids Name <br />Specs on File , Specs Submitted <br />_% <br />Placement Method Pumped Free Fall <br />Other A l S llJX ven f- DI p Q . <br />Seal Completion Complete with Mushroom Cap it bgs <br />Complete to Exl ing 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 REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE Nae Ne&UC TITLE Project Manager DATE 6/16/2021 <br />v <br />-j <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Area j4 S <br />Destruction Inspection By A � Date Employee ID#� <br />i <br />Codes Info Ina Bv.,. 'C S7Remitted / /ate �_ Service Request�l Invoice # Well ID# <br />evs4d3414/18 /'/ _�. -" WELL DESTRUCTION PERMIT <br />