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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes 9 No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091953-7697 FnR INRPFCTInNS FXPIRFS 1 YFeR FRnul nATF Iccl IFn <br />JOB ADDRESS 4004 Marfargoa Rd. <br />CITY/ZIP Stockton, CA 95215 <br />CROSS STREET E. of Hwy 99 APN 179-200-37 <br />PARCEL SIZE 2.79LAND USE APPLICATION # <br />OWNER_ Cynthia Agullera <br />PHONE 209-598-2180 <br />OWNER ADDRESS P.O. Box 30963 <br />CITY/STATE/ZIP Stockton, CA 95213 <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. <br />PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1930 Ladd Rd. <br />CITY/STATE/ZIP Modesto, CA 95356 <br />IR C-57 WELL DRILLING LICENSE NUMBER 290813 <br />EXPIRATION DATE 5-31-22 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />I�f C-57 Well Drilling <br />license Number 290813 Expiration Date 5-31-22 <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 Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well [ Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <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 M No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 6 inches Total Depth eSt, 1 05ft Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to est. 105 ft bgs Filler Material <br />from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement <br />sack mix17 gal water ❑ Bentonite <br />Pellets <br />X Bentonite (20% solids) Manufacturer Spec % solids % Name <br />Bariod Quik Grout Specs on File ❑ Specs Submitted <br />Placement Method X Pumped Free Fall <br />Other <br />Seal Completion X Complete with Mushroom Cap 4 ft bgs Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT <br />Application Accepted By /i <br />Destruction Inspection By <br />COMMENTS <br />USE ONLY / <br />Date JI ! 0 rx Area <br />Date J �'� Employee ID# <br />r <br />PE <br />Codes <br />SC Received <br />Info By <br />Amount ate Permit/ Invoice # j YVe ID# <br />Cash Remitted Service Request # <br />-1373 <br />i� f <br />e <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />