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I <br />WELL DESTRUCTION PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT CALL <br />PUBLIC WATER SYSTEM ❑ Yes M No <br />1868 East Hazelton Avenue-STOCKTON CA 95205 - (209) 468-3420 <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 980 Warren Rd. <br />CITY/zIP Ripon 95366 <br />CROSS STREET N. of 99 Frontage ApN 261-650-24 <br />PARCEL SIZE 5•84LAND USE APPLICATION # <br />OWNER DASCO Greenwood, LLC do Modesto Sand & Gravel PHONE 209-545-4425 Tracv <br />OWNER ADDRESS 6137 Hammett Ct. <br />CITY/STATE/ZIP Modesto, CA 95358 <br />CONTRACTOR Hennings Bros. Dflllinq Co., Inc. <br />PHONE 209-545-1185 <br />CONTRACTORADDRESS 1930 Ladd Rd. <br />CITY/STATEIZIP Modesto. CA 95356 <br />X C-57 WELL DRILLING LICENSE NUMBER 2gn81 .'i <br />EXPIRATION DATE 5-31-24 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATEIZIP <br />11 C-57 Well Drilling <br />License Number 290813 Expiration Date 5-31-24 <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Dale <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Dale <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safely Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In Cl Pit Well [( Inactive ❑ Test Hole <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent propertywith contamination (Address) <br />Known SoiliWater contaminants at adjacent property <br />ExISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other a. <br />Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes It below ground surface (bgs) Hole Diameter SAN IpFh s <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing it bgs Diameter of Conductor Casing ENIP u/, <br />8" PVC est. 10 —,! T Nh <br />Well Casing Diameter inches Total Depth Qt Depth to Water ft Depth of Casing IDS: : <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 It bgs toest. 100 It bgs Filler Material <br />Well casing to be perforated by one of the following methods: <br />❑ Mills Knife Number of cuts every _ft and/or_ <br />❑ Explosives ❑ Detonating cord ❑ with projectiles everyIt ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (941b bag/5-6 gal water) Sand Cement sack mix/7 gal water <br />Pellets <br />from <br />from It bgs to ft bgs <br />it bgs to ft bgs <br />Bentonite <br />X Bentonite (20% solids) Manufacturer Spec % solids % Name or10 - UI FOU t Specs on File Specs Submitted <br />Placement Method X Pumped Free Fall Other <br />Seal Completion X Complete with Mushroom Cap 5 R bgs Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />P <br />Application Accepted By_ <br />Destruction Inspection By <br />CONIMENTS f(—!�-"o <br />M E N T U S E O N <br />Dale <br />Dale <br />c e <br />Area G <br />Employee IDA <br />U e- U . �✓! �^— o -J f Gt 2 ,;L rt cz `� t v %` r <br />A- Ap �Jc� s L� ,Sni`/ f/ E'Y' ; c- rH-�7 i✓ GIM f to 1 -1 -SL' i , <br />PE Sc Received Che / <br />Codes Info By_ <br />Amount Date Permit] Invoice # <br />Remitted Service Re uest# <br />Well ID# <br />EHD 43.08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />