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WELL DESTRUCTION PERMIT #495 <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 />NON-RFrimnARI F PFRMIT CGI I l90g1 q53-7Rg7 Fr1R INSPFCTIr1NS FXPIRFS 1 YFAR FRnM BATF IRSllFn <br />JOB ADDRESS 295 AirportWay <br />CITY/ZIP Manteca, 95337 <br />2.73 <br />CROSS STREET West YnSPmitP AVPrujt- APN 19816022 <br />PARCEL SIZE acres LAND USE APPLICATION # <br />OWNER Tionette Rossi <br />PHONE 209-479-4363 <br />OWNER ADDRESS PO Box 837 <br />CITY/STATE/ZIP Ripon 95366 <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 <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 ® 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 ❑ Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached ❑ Yes El No Grout Seal ❑ No ❑ Yes <br />It below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes M No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 8 inch inches Total Depth 175 ft Depth to Water Unknown ft Depth of Casing 175 It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from Total Depth ft bgs to 0 It bgs Filler Material <br />None from It bgs to ft bgs <br />Well casing to be perforated by one of the following methods, _ <br />from 0 It bgs to 175 It bgs <br />❑ Mills Knife Number of cuts every ft and / or <br />12 Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ Without projectile <br />ES Detonating cord and boosters 13 with projectiles every <br />10 ft ❑ Without projectile <br />❑ Other <br />Sealing Material ✓Neat Cement (94 lb bag /5-6 gal water) Sand Cement sack mix /7 gal water Bentonite Pellets <br />Bentonite (20% solids Manufacturer Spec % solids _% Name <br />Specs on File Specs Submitted <br />Placement Method Pumped Free Fall <br />Other <br />Seal Completion Comp e e with us room Cap It bgs <br />Complet to 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE "/N Jit TITLE VP Operations DATE 03/29/019 <br />F& <br />Application Accepted By _ <br />Destruction Inspection By <br />COMMENTS <br />MENT USE O N L <br />Date Area pp <br />Date Employee ID#11/J� <br />Codes Info ash Remitted IDate Se ice Re uest# --Invoice# Well IDN <br />L-21 kAV4 .1 <br />EHD 43-08�� / WELL DESTRUCTION PERMIT <br />revised 4114/18 <br />H <br />Q�19 <br />N <br />