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EMA1�� <br /> WELL DESTRUCTION <br /> PERMIT - 2H c M <br /> PUBLIC WATER SYSTEM ❑Yes 9 No <br /> SAN JOAQUIN Cot ihTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUND LE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS"0 West Grant Line Road CITYfZIP Tracy,95391 � <br /> CROSS STREET Mall)"Lane APN 209-07-023 PARCEL SIZE 3'� LAND USE APPLICATION# c <br /> A <br /> OWNER Tri Pointe Homes PHONE(925)804-2266 <br /> �n <br /> OWNER ADDRESS 2700 Camino Ramon, Suite 130 CITYISTATEIZIP San Ramon,CA,94583 <br /> CONTRACTOR Pitcher Services,LLC PHONE(650)328-8910 <br /> CONTRACTOR ADDRESS 218 Demeter Street CITY/STATE/ZIP East Palo Allo,CA,94303 <br /> Q C-57 WELL DRILLING LICENSE NUMBER 1044895 EXPIRATION DATE 09P30/2024 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> ❑ C-57 Well Drilling License Number Expiration Date <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 O Replacement Well ❑ Caved In ❑ Pit Well D Inactive ❑ Test Hole <br /> Detected/Suspected Well Water Contaminant(s} <br /> Adjacent property with contamination(Address) <br /> Known SoIlMlater contaminants at adjacent property — <br /> ExisTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased IN Other Unknown <br /> Well Log copy attached ❑ Yes N No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter 6 inches <br /> Well Conductor Casing❑ Yes IN No Depth of Conductor Casing ft logs Diameter of Conductor Casing inches <br /> Well Casing Diameter 6 inches Total Depth Unknown ft Depth to Water Unknown ft Depth of Casing Unknown it bgs <br /> DESTRUCTION SPECIFICATION V\.J t- 'f�> 'Zt+'7 7'> <br /> Sealing Material from ft bgs to 0tmp°r-'*l ft logs Filler Material from it logs to it bgs <br /> Well casing to be perforated by one of the following methods: from it bgs to It bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile <br /> 0 Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile <br /> ❑ Other Wel,msng cf a eter<W.no perW.J n­eCed to plan far. <br /> PetlSealing Material m Neat Cement(94 lb ba915-6 gal water)❑ Sand Cement sack mbrll gal water ❑ Bentonite <br /> ❑ Bentonite(20%solids) l7 Manufacturer Spec%solids % Name ❑ Specs on File L. Specs Submitted <br /> Placement Method j Pumped ❑ Free Fall O Other Tremie Pipe grout to surface after establishing bottom of well <br /> Seal Completion t I Complete with Mushroom Cap ft bgs 0 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 1 Date Z Z Area <br /> �r <br /> Destruction Inspection By�- Date Employee ID# ^ T <br /> COMMENTS IrI 67 .'(L `'� 7 1L- Z f l �� qA / <br /> r� <br /> JOA <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Tfy aQf l`q Y <br /> Codes InfoB Cash Remitted Service Re uest# <br /> 4 WP0045 3(0 <br /> EHD 43-08 I �I�� h WELL DESTRUCTION PERMIT <br /> 11123121 <br />