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WELL DESTRUCTION PERMIT V.0 S O L e " PUBLIC WATER SYSTEM ❑ Yes ❑ No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-RFFiimnARI F PFRMIT rAI I ii Q91-7RQ7 FAR INCPFrTInNC FXPIRFS 1 YFAR FROM niATF IIRIIFn JOB ADDRESS In PROW IFO 16802 Von Sosten Rd, Clly/Zlp Tracy, CA95304 CROSS STREET Los Ranchos APN lFO 209-380-350-000 W ARCEL SIZE LAND USE APPLICATION # OWNER Pacific Gas and Electric Company PHONE 9254044064 OWNER ADDRESS 6121 Bollinger canyon Road, CITY/STATE/ZIP San Ramon, CA 94583 CONTRACTOR American Construction and Supply, Inc. PHONE 415-927-2024 CONTRACTOR ADDRESS 45 San Clemente Dr., Suite A-100 CITY/STATE/71P Corte Madera, CA 94925 C-57 WELL DRILLING LICENSE NUMBER 310599 EXPIRATION DATE 03/31/2023 PERFORATION CONTRACTOR N/A PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP 0 C-57 Well Drilling License Number 310599 Expiration Date 03/31/2023 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 1' Inactive ❑ Test Hole Detected/ Suspected Well Water Contaminant(s) N/A Adjacent property with contamination (Address) N/A Known Soil/ Water contaminants at adjacent property N/A EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes ft 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 _ inches Total Depth ft Depth to Water ft Depth of Casing _ ft bgs DESTRUCTION SPECIFICATION Sealing Material from 112' ft bgs to 0 ft 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 every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ odw Sealing Material Neat Cement 941b bag /5-6 al water Sand Cement sack mix / 7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids —% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other fill existing vent pipe Seal Completion Complete with Mushroom Cap 5' ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. eedd ��v1 L5s ��oo�f, MIh )UR 1;6J*69Nt7WZ'9W€QUIRED FOR INSPECTIONS Date: 2021.07.02 15:48:37 -07'00' Steve McKim, Vice President Jul 2, 2021 CONTRACTORS SIGNATURE TITLE DATE Y -1 DEPARTMENT USE ONJY ,q Application Accepted By /�� ' lDate 177 1 Area S'1,q —I Destruction Inspection By Ill t Date !4 1 I � 22- Employee ID# S COMMENTS LL-R�'hZd1_ 1 Rfl�Tet+ SM JdCl I PE Codes Codes SC Received Check#/ Info Cas Amount Date Permit/ Well ID# Remitted e e Re uest# LIM 161 q1 EHD 43-08 6+_�,•_ / /�� I J�� /l ,/ WELL DESTRUCTION PERMIT revised 4/14/18 f•� r