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I 0 WELL DESTRUCTION PERMIT #17926 PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NnN-RFFIINnARI F PFRMIT CAI I I20gl 953-7697 Fnp INRPFCTinw.q EXPIRES 1 YFAR FRr1M BATF IRSIIFn JOB ADDRESS 146 Airport Way CITY/ZIP Manteca 95337 CROSS STREET West Yosemite Ave APN 20014011 0.54 PARCEL SIZE Acres LAND USE APPLICATION # OWNER Russel and AJ Cassidy PHONE 209-823-4873; 209-922-9755 OWNER ADDRESS 625 EI Portal Ave CITY/STATE/ZIP Manteca, Ca, 95337 CONTRACTOR Cascade Drilling PHONE (916) 638-1169 CONTRACTOR ADDRESS 3000 Duluth Street CITY/STATE/ZIP West Sacramento, CA 95691 C-57 WELL DRILLING LICENSE NUMBER 938110 EXPIRATION DATE 09/30/2019 PERFORATION CONTRACTOR McMillan Well Services, LLC PHONE PERFORATION CONTRACTOR ADDRESS 12302 Andes Ave CITY/STATE/ZIP Bakerfield, CA 93312 ❑ C-57 Well Drilling License Number 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 9201 Expiration Date 4/5/2021 REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well IN Inactive ❑ Test Hole Detected / Suspected Well Water Contaminant(s) MTBE Adjacent property with contamination (Address) Known Soil / Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS IT Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other _ Well Log copy attached ❑ Yes I$ No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes 1:1 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 4.75 inches Total Depth 69 _ft Depth to Water Unknown it Depth of Casing 64.5 It bgs DESTRUCrION SPECIFICATION Sealing Material from Total Depthft bgs to 0 ft bgs Filler Material None from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from 0 ft bgs to 69 ft bgs ❑ Mills Knife Number of cuts every ft and / or 91 Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile R Detonating cord and boosters ® with projectiles every 10 ft ❑ without projectile ❑ Other Sealing Material vNeat Cement (94 Ib 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 Pum ed Free Fall Other Seal Completion Complete with Mushroom Cap ft bgs Com to 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. CONTRACTORS 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS l TITLE VP Operations DATE 03/29/2019 / P RTMENT USE ONLY Application Accepted By A Date Area Destruction Inspe� y'on By A l! Date Employee ID# COMMENTS /.d%yLLRlL�C11 '/. C7 ,?v-ri Lt _ _ it .,— Codes Info y.Bvn Cashrt Remitted Date I Service Request# I Irl06i I Well ID# EHD 43-08 0)4' WELL DESTRUCTION PERMIT revised 4/14/18 (l !!! 6 y J�N 'I dgQ��9 y�F MFNOU;Af