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WELL DESTRUCTION PERMIT #17911 <br />PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 147 Airport Way <br />ITY/ZIP Manteca 95337 <br />CROSS STREET West Yosemite Ave APN <br />- V ARCEL SIZE 0.14 LAND USE APPLICATION # <br />OWNER Karin Meyer <br />PHONE 209- 91374 <br />OWNER ADDRESS 370 N. Main Street <br />CITY/STATE/ZIP Manteca, CA 95336 <br />CONTRACTOR Cascade Drilling <br />PHONE (916) 638-1169 <br />CONTRACTOR ADDRESS 3000 Duluth Street <br />CITY/STATE/ZIP 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 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 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 <br />❑ Caved In ❑ Pit Well EX Inactive ❑ Test Hole <br />Detected/ Suspected Well Water Contaminant(s) MTBE <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom <br />❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes 0 No Grout Seal ❑ No <br />❑ Yes ft below ground surface (bgs) Hole Diameter Inches <br />Well Conductor Casing ❑ Yes [X No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter Unknown inches Total Depth UnknoWrft <br />Depth to Water Unknown it Depth of Casing Unknown ft bgs <br />DESTRUCTION SPECIFICATIO <br />Sealing Material fromTotal Depth It bgs to 0 It bgs Filler <br />Material None from it bgs to It bgs <br />Well casing to be perforated by one of the following methods: <br />from 0 it bgs to total depth ft bgs <br />❑ Mills Knife Number of cuts every <br />It and / or <br />LY Explosives ❑ Detonating cord ❑ With projectiles every It ❑ without projectile <br />Q Detonating cord and boosters EX with projectiles every 10 It ❑ Without projectile <br />❑ Other <br />Sealing Material V/Neat Cement (94 lb bag / 5-6 gal water) <br />Sand Cement sack mix /7 gal water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec % solids_% <br />Name Specs on File Specs Submitted <br />Placement Method I PumpedFree Fall <br />Other <br />Seal Completion Complete with Mushroom Cap <br />it bgs CompletELto Existing Surface Pad eeej <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 SIGNATUR <br />Application Accepted By_ <br />Destruction Inspection By l <br />COMMENTS / MiliI <br />48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />l� TITLE VP Operations DATE 03/29/2019 <br />,EP RTMENT USE O/NL� <br />Date <br />Date <br />■I1ti�i�i•�il�iliiti�MYiiYY��ifli���Fft•� _ _ �'i]sf7 e:7 ��riR4IIh� <br />EHD 43-08 <br />revised 4/14/18 <br />S2L5yllsl <br />WELL DESTRUCTION PERMIT <br />