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' WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM [:]Yes [XI 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 640 E. Eleventh St. <br />CROSS STREET E. of MacArthur Dr. APN 250-25-015 <br />OWNER Sunny Ghai/Ghai Management Services, Inc. <br />OWNER ADDRESS 25 F Airway Blvd. CITY/STATE/ZIP Livermore, CA 94551 <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br />CITY/ZIP Tracy, 95376 <br />PARCEL SIZE .97 LAND USE APPLICATION # <br />PHONE 510-573-5905 <br />CONTRACTOR ADDRESS -1 930 Ladd Rd. CITY/STATE/ZIP Modesto, Ca 95356 <br />C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2024 <br />PERFORATION CONTRACTOR <br />PERFORATION CONTRACTOR ADDRESS <br />b C-57 Well Drilling <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />❑ CHP Hazardous Material Transportation for Explosives <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />❑ California Occupational Safety Health - Blaster <br />CITY/STATE/ZIP <br />License Number 290813 Expiration Date 5-31-24 <br />License Number <br />Expiration Date <br />License Number <br />Expiration Date <br />License Number <br />Expiration Date <br />License Number <br />Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In <br />Detected/Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil/Water contaminants at adjacent property <br />❑ Pit Well 0 Inactive ❑ T-tTMI1 ��l <br />L-/1 <br />EXISTING WELL CONSTRUCTION DETAILS ElOpen Bottom ❑ Gravel Pack ❑ Uncased ❑ Other ­IV <br />JOAQ <br />vIR0Well Log copy attached El Yes if No Grout Seal ❑ No 13 Yes ft below ground surface (bgs) Hole Diamm&Al 4 NM T <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing <br />Well Casing Diameter '12 inches Total Depth est. 54'ft Depth to Water /u2 ft Depth of Casing Rft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from ft bgs to 54 ft bgs Filler Material _ from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every It and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) � Sand Cement 2 parts Sand Sack mix/7 gal water Bentonite <br />Pellets 1 part cement <br />Bentonite (20% solids) ❑ Manufacturer Spec %solids_ �^ ^' Sec n Fil <br />Placement Method Pumped Free Fall <br />Seal Completion Complete with Mushroom Cap <br />V <br />so e <br />Other <br />4 ft bgs Complete to Existing Surface Pad <br />Specs Submitted <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />T <br />PE <br />Codes <br />DEPARTMENT <br />USE ONlLY <br />Permit/ Invoice # Well ID# <br />Service Request # <br />Application Accepted By �- <br />�� Z --Date <br />Ll Area S <br />`�%� <br />Destruction Inspection By <br />tiu--ice/ <br />�F/'� <br />Date 7� '" — Z2. Employee ID# <br />YI <br />COMMENTS rYr Qt rr�v1 <br />�.O:I:�C�)n(' iir0 OKz �/ Fo <br />r-�S ray'yJ: Fi1,Ui Cvf fJ• :}inrl <br />L <br />ti,!`/1n <br />11.y7 <br />j.j t t 3 vt L'� - <br />T <br />PE <br />Codes <br />SC Received <br />Info Bv <br />Amount Date <br />Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />L431`I <br />_" <br />3d s <br />r <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23J21 <br />