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• E11�q�L�� <br /> WELL DESTRUCTION PERMIT 2L4 C, M <br /> PUBLIC WATER SYSTEM ❑Yes ®❑No <br /> SAN JOAQUIN CO TY 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 1 YEAR FROM DATE ISSUED <br /> J: <br /> JOB ADDRESS4"' O West Grant Line Road CITY/Zip Tracy,95391 1 <br /> CROSS STREET Malberry Lane ApN 209-07-023 PARCEL SIZE 3 2a LAND USE APPLICATION# O <br /> OWNER Tri Pointe Homes PHONE(925)804-2266 <br /> OWNER AODRESS 2700 Camino Ramon,Suite 130 CITYISTATEJZIP San Ramon, CA, 94583 <br /> CONTRACTOR Pilcher Services,LLC PHONE(6 50)328-8910 <br /> CONTRACTOR ADDRESS 118 Demeter Street CITY/STATE/ZIp East Palo Alto,CA,94303 <br /> Q C-57 WELL DRILLING LICENSE NUMBER 10't'1895 EXPIRATION DATE 09/30/2024 <br /> PERFORATION CONTRACTOR PHONE <br /> PERFORATION CONTRACTOR ADDRESS CITYISTATEIZIP <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 ❑ 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 SoilNVater contaminants at adjacent property_ <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased M Other Unknown <br /> Well Log copy attached ❑ Yes IN 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 It bgs Diameter of Conductor Casing inches <br /> Well Casing Diameter 6 inches Total Depth Unknown ft Depth to Water Unknown ft Depth of Casing Unknown ft bgs <br /> DESTRUCTION SPECIFICATION CV V(-a--—'4r' T�> .�t�) 7�y <br /> Sealing Material from ° ""xea" Ill 0('P°`­"r"j ft bgs Filler Material from it bgs to R 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 everyIt ❑ without projectile <br /> ❑ Other Yfei.ras^ig diar^e;er c fl no per'oralms nee[ed to plan for. <br /> Sealing Material El Neat Cement(94 lb bag/5-6 gal water)H Sand Cement sack mix/7 gal water C Bentonite <br /> Pellets <br /> ❑ Bentonite(20%solids) [I Manufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement Method Pumped : Free Fall I] Other TrnmiePipegrouttosurfacealerestabrishingbottomofwell <br /> Seal Completion I I Complete With Mushroom Cap ft bgs 171 Complete to Existing Surface Pad <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL(209)953-7697 FOR INSPECTIONS <br /> DEPARTMENT USE OZ N Y f r <br /> Application Accepted By / Date Z l t Area <br /> Destruction Inspection By Date Employee ID# <br /> COMMENTS l..1�6� i�LLb-A'7 7�L > Z f 1 iL �� _ ^1 T A/I r�IV <br /> r <br /> Fal <br /> .4 <br /> "H N�0 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Ty�y� qL Y <br /> Codes Info B Cash Remitted Service Request# <br /> CU � � a ) 43(6 <br /> EHD 43-08 /� WELL DESTRUCTION PERMIT <br /> 11/23/21 IJV J <br />