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DeceSign Enve;ope ID:9195FF3F-01B2-4CB9-A5CD-B9867BBF5748 <br /> WELL DESTRUCTION PERMIT <br /> owl PUBLIC WATER SYSTEM ❑Yes [�No <br /> SAN JOAQUIN C UNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /) JOB ADDRESS N. side of Corral Hollow Rd. clTYizIP Tracy, CA 95377 <br /> CROSS STREET W. of 1-580 ramp APN 251-060-12 PARCEL SIZE357 LAND USE APPLICATION# <br /> OWNER Lennar Hms of CA PHONE 209-835-0610 Victoria <br /> OWNER ADDRESS c/o Engeo 17278 Golden Valley Parkway ____CITY/STATE1ZIP Lathrop, CA 95330 I " <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto CA 95356 <br /> 6 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2022 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS _CITY/STATE/ZIP <br /> IX C-57 Well Drilling License Number 290813 Expiration Date 5-31-22 <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date <br /> ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br /> ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> ❑ California Occupational Safely Health-Blaster License Number Expiration Date <br /> REASON FOR DESTRUC nONv ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive ❑ Ast Hole 1 <br /> Detected/Suspected Well Water Contaminant(s) App,.__r <br /> Adjacent property with contamination(Address/ <br /> Known Soil./Water contaminants at adjacent property _-_-_ --_ - PrJ <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other <br /> q� <br /> Well Log copy attached ❑ Yes 15 No Grout Seat ❑ Nn ❑ Yes __ It below ground surface(bgs) Hole DiaTfii?�(�d <br /> CCu,.,� <br /> Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor IR <br /> 'JV"0"y <br /> Well Casing Diameter 8 Steed inches Total Depth est. 3rJQ'fj Depth to Water___ _ ft Depth of Casin_DEPART bgs <br /> DESTRUCTION SPECIFICATION 2► <br /> Sealing Material frcm 0 ft bgs to est. bgs Filler Material from ft bgs to _ ft bgs <br /> Well casing to be perforated by one of the following methods: from it bgs to, ft bgs <br /> ❑ Mills Knife Number of cuts every---_ __ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles every it ❑ without projectile <br /> ❑ Detonating cord and boosters ❑ with projectiles everyit ❑ without projectile <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Ib bao-6 gal water) X Sand Cement a sack mix/7 gal water Bentonite <br /> Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids % Name Specs on File Specs Submitted <br /> Placement Method X Pumped Free Fall Other <br /> Seal Completion X Complete with Mushroom Cap 5' ft bgs Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> >� z <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �� �"L C— Date t "Z �r� _ Area � <br /> Destruction Inspection By. ` _ Date L i �i ✓ Employee ID# <br /> COMMENTS_ _ <br /> PE SC Received hec Amount Permit/ <br /> Info Date Remitted ServiceRequest# Invoice# Well ID# <br /> , <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 11/23/21 <br />