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WELL DESTRUCTION PERMIT s 6"STEEL 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 18389 McKinley Ave. CITY2IP Manteca 95337 " /� p m CROSS STREET S.Yosemite Ave.. APN 241-400-29 PARCEL SIZE 15.QaND USE APPLICATION# OWNER Yosemite-McKinley Three LLC c/o RB EnvironmentalHONE 209-740-8205 OWNER ADDRESS 4460 S. Hwy 99 Frontage Rd. CITY/STATE/ZIP Stockton, CA 95215 CONTRACTOR Hennings Rros Chilling rn Inc PNONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATErzIP Modesto, CA 95356 XC-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2022 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 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 Dale California Occupational Safety Health-Blaster License Number Expiration Dale REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well [X Inactive O 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 IX 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 Diameter6" Steel inches Total DepttieSt. 1 50tt Depth to Water h Depth of Casing est.1 5Q ft bgs DESTRLC'TIUS 5PF.C'IFR ATION Sealing Material from 0 ft bgs to est.150ftbqs 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 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUI E CTI CONTRACTORS SIGNATOR L V.P. DATE Nov 22,2021 I I l I I I V1 e pF ® 0 gRN71� 7- I MENT DEPARTMENT USE ONL 1 Application Accepted By "�— ` Date 1 2 `�r .� Area 1.G/�; �1 7Q Q Destruction Inspection By Date�tiI -7 Z� Employee ID# his —T— COMMENTS PE Sc Received Chec Amount Date Permit] Invoice# Well ID# Codes Info Remitted Service Request# Zq 373 IC ' 2 EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07