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WELL DESTRUCTION PERMIT <br />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 (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 320 N. Airport Way <br />CITY/ZIP Manteca 95337 <br />CROSS STREET N. of Hwy 120 bypass APN 200-14-026 <br />PARCEL SIZE1 3.21AND USE APPLICATION # <br />OWNER Kiper, Inc <br />PHONE 209-768-3175 Tracy <br />OWNER ADDRESS 3200 Danville Blvd. , Ste. 200 <br />CITY/STATE/ZIP Alamo, CA 94507 <br />CONTRACTOR Hennings Bros. Drilling Co.. Inc. <br />PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1930 Ladd Rd. <br />CITY/STATEIZIP Modesto, CA 95356 <br />b C-57 WELL DRILLING LICENSE NUMBER 290813 <br />EXPIRATION DATE May 31, 2024 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATEIZIP <br />.C7 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 ❑ Te �t <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 <br />Pack ❑ Uncased ❑ Other JCA <br />Well Log copy attached ❑ Yes ff. No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole DiametRCN V <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conduc Casing <br />ft bgs Diameter of Conductor Casing PA�9l <br />Well Casing Diameter 6" Steel inches Total Depth ft Depth to Water 20 ft Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION /0,0 <br />Sealing Material from 0 ft bgs to -a4' _ft bgs Filler Material <br />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 />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement <br />sack mix/7 gal water Bentonite <br />Pellets <br />Bentonite (20% solids) n Manufacturer Spec % solids % Name <br />Specs on File Specs Submitted <br />Placement Method 11Pumped Free Fall <br />Other <br />Seal Completion %' Complete with Mushroom Cap ft bgs <br />Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT USE ONLY j <br />Application Accepted By — /Z L Date )OJAA� -�Area <br />Destruction Inspection By ��s����� e1Q Date le -1 <br />"/7 7c ' 1-Z- Employee ID# <br />COMMENTS <br />T <br />!J <br />PE <br />Codes <br />Sc Received C Check#/ <br />Info B <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest # <br />V3 <br />!0 <br />T15- IQUt 22 <br />M9004L <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />