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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes [�f 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 ADDRESS 21399 S. Carrolton 44mel f a,. CITY/ZIP Ripon 795366 CROSS STREET North of River Rd. APN 245-220-02 PARCEL SIZE 39.9 LAND USE APPLICATION# OWNER Fondse Farms Trucking PHONE 209-484-0495 m v OWNER ADDRESS P.O. Box 904 CITY/STATE/ZIP Ripon. CA 95366 CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 1T C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE 5-31-22 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP M C-57 Well Drilling License Number 290813 Expiration Date 5-31-22 ❑ 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 Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes IX No Grout Seal ❑ No ❑ Yes It below ground surface(bgs) Hole Diameter inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 6" steel inches Total Depth est.150 It Depth to Water ft Depth of Casing est.150 ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs toeSt.150 ft bgs Filler Material from ft bgs to It 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 every It ❑ without projectile PA M ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other RECEID Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water El Bentonite Pellets {{.. 1 {; ll X Bentonite(20%solids) Manufacturer Spec%solids % Name Quik Grout Specs on File Specs'8' 4it'0 � Placement Method X Pumped Free Fall Other OAQUIN C UNTY Seal Completion Complete with Mushroom Cap ft bgs X Complete to Existing Surface Pad ENVIRONMENTAL MENT MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS /' DEPARTMENT USE ONLY 7 ` J�� 1 Application Accepted By Date ��Zpy ! L" Area / Destruction Inspection By Date Z /�Yl/ �i2 Employee ID# �OMMENTS e-tl LA-/ �l L' G'/�: �t�c' C' Y0.�� IO drd T i i � v c.� 1 L� �N L �( �ct�o PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info s Remitted Service Request# 2 23 22 0 AN L4 2-q I EHD 43-08 WELL DESTRUCTION PERMIT 11/23/21