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WELL DESTRUCTION PERMIT <br />C -1923 -Destruction PUBLIC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 12flAl 4."-7RA7 FnR IN1tPFrTInNC FXPIRFC 1 VFAo Fonlu nATc Ieci mn <br />JOB ADDRESS E Cherokee Rd and Lagorio <br />CITYIZIP Stockton Ca <br />CROSS STREET Lagorio APN Near 08717010 <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER PG&E <br />PHONE 925-719-4929 <br />OWNER ADDRESS 4040 West LN <br />CITYISTATE/ZIP Stockton, Ca 95204 <br />CONTRACTOR Gregory Drilling <br />PHONE 530-565-6289 <br />CONTRACTOR ADDRESS 14112 452nd Ave SE <br />CITYISTATE/ZIP North Bend, Wa 98045 <br />C-57 WELL DRILLING LICENSE NUMBER 1007649 <br />EXPIRATION DATE 1-31-23 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <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 M Other Cathodic Protection <br />Well Log copy attached ❑ Yes DO 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 1 inches Total Depth ft Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to 115 ft bgs Filler Material <br />Neat Cement 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 />PAYMENT <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectilekECEIVED <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />q <br />Material X Neat Cement (94 lb bag/5-6 gal water) Sand Cement <br />�(� <br />sack mix17 gal water nZ022 <br />J U NBZ <br />Pellets ling <br />Bentonite (20% solids) Manufacturer Spec % solids % Name <br />Specs on File °AEN Uw TY. <br />�' ` 'mltted <br />Placement Method X Pumped Free Fall <br />Other HEALTH DEPARTMENT <br />Seal Completion k Complete with Mushroom Cap 51 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 �Z L-/— Date a Area 11� <br />Destruction Inspection By csfa"" Date ��._ZG' Employee ID# Y v1 K G <br />COMMENIT'S ? I C Y b Te ��N P F f e✓ JJV? r S 6 I U F <br />un C(Pf S paYMA, <br />PE SC Received <br />Codes Info B <br />Check#/ Amount Permit/ <br />C s Remitted at Service Requ st # <br />Invoice # Well ID# <br />q ps <br />V1 "27T 419"5'-d <br />EHD43-08 �" �V 3 5 6 /��Z WELL DESTRUCTION PERMIT <br />11/23/21 <br />