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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes I1 No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091 953-7697 FoR INSPFrTInNs FXPIRFR 1 YFAP FwnM nATF IQCZIIFn <br />JOB ADDRESS 17423 S. Enterprise Rd. <br />CITY/ZIP Escalon 95320 <br />CROSS STREET N. of Hwy 120 APN 229-26-004 <br />PARCEL SIZE 1 •0OLAND USE APPLICATION # <br />OWNER Andrew Anderson <br />PHONE 209-404-9550 <br />OWNER ADDRESS 17423 S. Enterprise Rd. <br />CITY/STATE/ZIP Escalon, CA 95320 <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 />tY C-57 WELL DRILLING LICENSE NUMBER 290813 <br />EXPIRATION DATE 5-31-24 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />b 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 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 ❑ 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 <br />Well Log copy attached ❑ Yes q No Grout Seal ❑ No ❑ Yes <br />It 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 />n <br />Well Casing Diameter inches Total Depth It Depth to Water ft Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from U ft bgs to UnknOWfTt bgs Filler Material <br />from ft bgs to <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to I 'r I <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile q UG <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile Q <br />❑ Other <br />SA N <br />JO <br />Material Neat Cement (94 Ib bag/5-6 gal water) r1 Sand Cement <br />sack mix/7 gal water U/ <br />N <br />Pellets ling <br />��at7ltic O O <br />A�T9 N/," C <br />X Bentonite (20% solids) Manufacturer Spec % solids % Name <br />Quik Grout -i Specs on File Specs ��7 <br />Placement Method X Pumped Free Fall <br />Other 7� <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 ON Y //�� <br />Application Accepted By ��� ��L Date 7 a 17 Area q nn //� <br />Destruction Inspection By Date �� �� h ��Z L— Employee ID# A G <br />COMMENTS r I► h V r Oul 50C14 drplh / r"en I'/� <br />f')o"Y'k (,-(-"Je11 Iiia nH/YI rnV'�i!' e Dn <br />pyltf )< CUP('/ I.zjetjktremI ClP0�l1 6f .,,,iA / <br />T <br />a <br />O <br />X <br />vm, <br />rn <br />jjTy <br />PE Sc Received Chec Amount <br />Codes Info B Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />`13(.8 u60 Ism <br />d e <br />yv; L'U�IS�� <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />