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WELL DESTRUCTION PERMIT \ 00 TIN C.*'t 1_VJG 1.C PUBLIC WATER SYSTEM ❑Yes n 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 m JOB ADDRESS 3128 W.Yosemite Ave. CITY21P Manteca 95337 CROSS STREET W.of McKinley Ave. APN 241-280-12 PARCEL SIZE31.31ND USE APPLICATION# OWNER Yosemite-McKinley Three LLC c/o RB EnvironmentalHONE 209-740-8205 OWNERADDRESs 4460 S. Hwy 99 Frontage Rd. CITY/STATE/ZIP Stockton, CA 95215 CONTRACTOR Hennings Bros nrilling Co Inc PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE21P Modesto. CA 95356 XC-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2022 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP r 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 [( Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Pump is still in well Known Soil/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&' steel inches Total DeptteSt. 1% Depth to Water It Depth of Casing est.150 ft bgs DESTRL CTIOS SPECIFICATION Sealing Material from O ft bgs to est.150 t 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 it ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 1b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets XBentonite(20%solids) Manufacturer Spec%solids_% Name QUIko� rOW 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARDkNDHAT IAM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE R QUI `' ECTIONS CONTRACTORS SIGNATURE I T E V•P• DATE Nov. 22, 2021 I I 6j I - �- `- 4)% 1 I0 10121 �GTy� pq� 4ry FiyT DEPARTMENT USE ONLY _ 1 Application Accepted By F— i- —`'L Date 7 ZA Lg 1 Area L' t n r 0 12 Destruction Inspection B Date J'Z- Employee ID# 4< COMMENTS PE SC Received Ch Amount a Permit/ Invoice# Well ID# Codes Info By- RemittedService Request# ,37 1�1 I�5' Z END 43-08 WELL DESTRUCTION PERMIT 10/5/07