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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM [:]Yes [t No <br />SAN JOAQUIN COUNTY 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 4620 E. Shippee Ln. <br />CITY/ZIP Stockton, CA 95212 <br />J� / /� <br />CROSS STREET S.W. corner of Gnekow DrAPN Q KSV 0 n rl <br />PARCEL SIZE' •37 LAND USE APPLICATION # <br />OWNER Sam & Ileen Rith <br />PHONE 209-629-1230 <br />OWNER ADDRESS 4683 Pebble Beach Dr. <br />CITY/STATE/ZIP Stockton, CA 95219 <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 />IX 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 />t 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 IN 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 Allf <br />Well Log copy attached ❑ Yes rY No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diamet� inc e� <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casm M;,,,UlN,0t3"p <br />Well Casing Diameter 6., steel inches Total Depth est. 1 50f Depth to Water ft Depth of C± <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to est. 1 50'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 mix/7 gal water ❑ Bentonite <br />Pellets <br />X Bentonite (20% solids) Manufacturer Spec % solids % Name <br />Quik Grout Specs on File ❑ Specs Submitted <br />Placement Method X Pumped Free Fall <br />Other <br />Seal Completion Complete with Mushroom Cap ft bgs X Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONLY <br />Application Accepted By Date `IA2 a Area -7 <br />Destruction Inspection By Date 7 �171 Employee ID# <br />COMMENTS ln�Pl� il'S UkC. (/ �o ��r.�hlF se, 1 <br />PE <br />Codes <br />SC Received hec Amount Date <br />Info B sh Remitted <br />Permit/ Invoice # <br />Service Request # <br />Well ID# <br />L�3 <br />3 <br />E <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23121 <br />