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WELL DESTRUCTION PERMIT #17793 <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 />GALL (ZUyI ybS-rbUf t -OR <br />JOB ADDRESS 207 AirportWay <br />CITY/ZIP Manteca 95337 <br />CROSS STREET West Yosemite Avenue APN 19817048' <br />PARCEL SIZE . 0 AND USE APPLICATION # <br />OWNER Dorothy Mack <br />PHONE 209-823-7466 <br />OWNER ADDRESS 185 Airport <br />CITY/STATE/ZIP Manteca 95337 <br />CONTRACTOR Cascade Drilling <br />PHONE(916)638-1169 <br />CONTRACTOR ADDRESS 3000 Duluth Street <br />CITY/STATEZP West Sacramento, CA 95691 <br />C-57 WELL DRILLING LICENSE NUMBER 938110 <br />EXPIRATION DATE 09/30/2019 <br />PERFORATION CONTRACTOR McMillan Well Services, LLC <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS 12302 Andes Ave <br />CITY/STATE/ZIP Bakerfield, CA 93312 <br />❑ C-57 Well Drilling <br />License Number Expiration Date <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 9201 Expiration Date 4/5/2021 <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well [9 Inactive ❑ Test Hole <br />Detected/ Suspected Well Water Contaminants) MTBE <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes IX No Grout Seal ❑ No ❑ Yes ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes Q No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter nkno n inches Total Depth UnknOWIA Depth to Water Unknown ft Depth of Casing Unknow nft bgs <br />Sealing Material from Total Depthftbgs to o ft bgs Filler Material None from <br />Well casing to be perforated by one of the of the following methods: from 0 <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ With projectiles every ft ❑ without projectile <br />❑ Detonating cord and boosters IX With projectiles every 10 it ❑ without projectile <br />ft bgs to ft bgs <br />ft bgs to total depth it bgs <br />❑ Other <br />Sealing Material /Neat Cement (94 lb bag 15-6 gal water) Sand Cement sack mix / 7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids_% Name Specs on File Specs Submitted <br />Placement Method Pum ed Free Fall Other <br />Seal Completion Complete with Mushroom Cap ft bgs Completeo Existing 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 />CONTRACTORS <br />Application Accepted By _ <br />DestructionInspe n By <br />COMMENTS <br />MINIUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE VP Operations DATE 03/29/2019 <br />TENT USE O[VL <br />Date !/ <br />a <br />°v <br />is <br />j 3q V,1O q 9 Z019 <br />W.-WAM-40-1-1 <br />PE I SC I Received eck#/ Amount Date J Permit/ Invoice # Well ID# <br />Codes Info Remitted §Mice Re vest# <br />EHD 43-08 if 5( WELL DESTRUCTION PERMIT <br />revised 4114118 <br />