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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [:3 No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDR 0 Corral Hollow Rd. CITY/ZIP Tracy, CA 95377 R CROSS STREET W• Of 1-580 ramp APN 251-060-10 PARCEL SIZE71•8 LAND USE APPLICATION# o OWNER Lennar Hms of CA PHONE 209-835-0610 OWNER ADDRESS C/o Engeo 17278 Golden Valley Parkway CITY/STATE/ZIP Lathrop, CA 95330 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 LT C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE 5-31-22 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP C-57 Well Drilling License Number Expiration Data ❑ 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 Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well CX Inactive ❑ Test Hple Detected/Suspected Well Water Contaminant(s) 'L•�0 _ Adjacent property with contamination(Address) 'ASV _ Known Soil/Water contaminants at adjacent property F�' � EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other FTq 7y Well Log copy attached ❑ Yes IX No Grout Seal ❑ No ❑ Yes ____ft below ground surface(bgs) Hole Diameter inch",*16,T Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter $ Steel inches Total Depth est. 350ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to est. 350ft bgs Filler Material from —ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other___" Sealing Material Neat Cement(94 Ib bag/5-6 gal water) X Sand Cement 211 sack mix17 gal water Bentonite Pellets Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name Specs on File Specs Submitted Placement Method X Pumped Free Fall Other Seal Completion X Complete with Mushroom Cap 5 ft bgs Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS DEPARTMENT USE ONLY Application Accepted By ��LI Date ger . (f 107 vt Area Destruction Inspection By /��"_ Date 2`I ?�OJ-Z Employee ID# COMMENTS 2- (SeoP(Seo PE E Sc Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info By s Remitted Service Request# `►373 � . 1 `7 I"' Z•0I 22 POOH EHD 43-08 WELL DESTRUCTION PERMIT 11/23/21