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WELL DESTRUCTION PERMIT <br /> PUBLIC WATER SYSTEM ❑YeWo 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 /> C <br /> JOB ADDRESS g CITY/ZIP 26372 Magnolia Ave. Escalon 95320 <br /> � <br /> m <br /> CROSS STREET E. Of ESCalon-Bellota Rd. APN 22908020 PARCEL SIZE 9.7`-Q AND USE APPLICATION# C <br /> OWNER Randy Schmidt PHONE 209-838-7337 <br /> OWNER ADDRESS 1463 Roosevelt Ave. CITY/STATE/ZIP EScalon,CA 95320 <br /> CONTRACTOR Hennings Bros. Drilling CO., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITYISTATE/ZIP Modesto,CA 95356 <br /> M C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31,2024 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP <br /> * C-57 Well Drilling License Number 290813 Expiration Date 5-31-24 <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 0 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 XXOther Unkown <br /> Well Log copy attached ❑ Yes la No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes 0 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter 6 inches Total Depth 80 ft Depth to Water ft Depth of Casing ft bgs <br /> DESTRUCTION SPECIFICATION <br /> Sealing Material from 0 ft bgs to 80 ft bgs Filler Material n/a 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/b bagl5-6 gal water)❑ Sand Cement sack rnbU7 gal water ❑ Bentonite <br /> Pel lets <br /> XX Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name Bariod-Quik GrOUt ❑ Specs on File ❑ Specs Submitted <br /> Placement MethoA XXX Pumped ❑ Free Fall ❑ Other <br /> Seal Completion Complete with Mushroom Cap 5' ft bgs ❑ Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> pEPARTMENT USE OMLY / <br /> Application Accepted By ` Date C� � L( � L � Area i240 <br /> Destruction Inspection By !G� {i`� 1 Date 7,44 Employee ID# <br /> COMMENTS fir: <<4 l l d�(�.15 ��.,` U r�L�ly�i C{ i val tk5��c�l�L��u Ir _/vT <br /> An- <br /> if �® <br /> JO <br /> NE,gLr'sfu #g IY <br /> ,V rA4 <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 4-a6-0, <br /> EHD 43-08 WELL DESTRUCTION PERMIT <br /> 11/23121 <br />