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WELL DESTRUCTION PERMIT #17821 PUBLIC WATER SYSTEM ❑ Yes ® 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 JOB ADDRESS 185 Airport Way CITY/ZIP Manteca 95337 CROSS STREET West Yosemite Ave APN17 1.09 PARCEL SIZE Acres LAND USE APPLICATION # OWNER Dorothy Mack PHONE 209-823-7466 OWNER ADDRESS 185 Airport Way CITY/STATEIZIP 185 Airport Way 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 936110 EXPIRATION DATE 09/30/2019 PERFORATION CONTRACTOR McMillan Well Services, LLC PHONE PERFORATION CONTRACTOR ADDRESS 12302 Andes Ave CITY/STATEIZIP 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 M 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 ❑ Open Bottom 11 Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes M No Grout Seal ❑ No ❑ Yes It below ground surface (bgs) Hole Diameter inches Well Conductor Casing ❑ Yes EX No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 6 inches Total Depth 115 It Depth to Water Unknown it Depth of Casing 155 ft bgs DESTRUCTION SPECIFICATION Sealing Material from Total De tp_h ft bgs to 0 ft bgs Filler Material None from ft bgs to It bgs Well casing to be perforated by one of the following methods: from 0 ftbgs to 115 ft bgs ❑ Mills Knife Number of cuts every ft and / or (FI Explosives ❑ Detonating cord ❑ With projectiles every ft ❑ without projectile ® Detonating cord and boosters m With projectiles every 10 ft ❑ Without projectile ❑ Other Sealing Material /Neat Cement (94 lb bag / 5-6 gal water) Sand Cement sack mix /7 gal water Bentonite Pellets Bentonite (20% solids) facturer Spec % solids_% Name Specs on File Specs Submitted Placement Method Fumpedl Free Fall Other Seal Completion Complete with Mushroom Cap it bgs Complet 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 SIGNA Application Accepted By Destruction Inspe on B COMMENTS /". 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PSA TMENT USE O Date 3/29/201 �4.'Jufv- —, 9®f AlV �pqQ PE SC Received Date Invoice # Well ID# Check#/ Amount Permit/Codes Info B ash emitted Se ice Re uest# .19I EHD 43-08 revised 4/14/18 WELL DESTRUCTION PERMIT