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WELL DESTRUCTION PERMIT <br />' - PUBLIC WATER SYSTEM ❑ Yes U/J 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 17400 W. Bethany Rd. CITY21P Mountain House 95391 <br />CROSS STREET E. of Byron Rd. APN 209-15-029 PARCEL SIZE 3'00 LAND USE APPLICATION # <br />OWNER Pinnacle Ridge LLC PHONE 925-605-6762 <br />OWNER ADDRESS 21315 San Jose Rd. CITY/STATE/zIP Tracy, CA 95304 <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1 ()'If) I ar1r1 RfI CITY/STATE/ZIP Modesto, CA 95356 <br />El C-57 WELL DRILLING LICENSE NUMBER 29013 EXPIRATION DATE 5-31-23 <br />PERFORATION CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br />n C-57 Well Drilling License Number 290813 Expiration Date 5-31-23 <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster 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 Gs. Gravel Pack ❑ Uncased ❑ Other <br />Well Log copy attached LQ Yes ❑ No Grout Seal ❑ No ls( Yes i 0'` ft below ground surface (bgs) Hole Diameter J inches <br />Well Conductor Casing ❑ Yes C: No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter inches Total Depth '% 5 ft Depth to Water 30 ft Depth of Casing 285 ft bgs <br />DESTRUCTION SPECIFICATION <br />c:. <br />Sealing Material from ft bgs to 'l 8 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 ft 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 sack mix/7 gal water Bentonite <br />Pellets <br />„ Bentonite (20% solids) Manufacturer Spec % solids % Name Bariod Quik -Grout Specs on File Specs Submitted <br />Placement Method X Pumped Free Fall Other <br />Seal Completion 11 Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />M <br />a <br />C <br />C <br />x <br />PE <br />Codes <br />DEPARTMENT USE ONLY <br />/�CJ <br />e <br />Date Permit/ InvoicQEP T A4Nell ID# <br />Service Re t # M <br />Application Accepted By_ <br />Date <br />Area <br />bi 'At! 114 'T <br />Ie <br />Destruction Inspection By <br />Date �-7-2 <br />7 Z <br />Employee ID# <br />COMMENTS 2 S- I <br />i cA ; <br />P <br />M <br />a <br />C <br />C <br />x <br />PE <br />Codes <br />SC Receivedhec <br />Info B <br />Amount <br />ash emitted <br />e <br />Date Permit/ InvoicQEP T A4Nell ID# <br />Service Re t # M <br />L13 73 <br />2 f2- <br />bi 'At! 114 'T <br />Ie <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />