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EMAILED WELL DESTRUCTION PERMIT _ pkv PUBLICWATEY �� li SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468-3420 NON-REFUN 4BLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 60 West Grant Line Road CITYIZIp Tracy,95391 i CROSS STREET Malberry Lane APN 209-07-023 PARCEL SIZE Saves LAND USE APPLICATION# o A OWNER Tri Pointe Homes PHONE(925)804-2266 1 n OWNER ADDRESS 2700 Camino Ramon, Suite 130 CITY/STATE/Zip San Ramon, CA, 94583 CONTRACTOR Pitcher Services,LLC PHONE(650)328-8910 CONTRACTOR ADDRESS 218 Demeter Street CITYISTATEIZIp East Palo Alto,CA,94303 EI C•57 WELL DRILLING LICENSE NUMBER 1044895 EXPIRATION DATE 09/3012024 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATEIZIP ❑ C-57 Well Drilling License Number Expiration Date ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date ❑ Califomla Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well O Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property -- EMS nNG -EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased 10 Other Unknown Well Log copy attached ❑ Yes 11 No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter 6 inches Well Conductor Casing❑ Yes ld No Depth of Conductor Casing -_ ft bgs Diameter of Conductor Casing inches Well Casing Diameter 6 inches'` Total Depth Unknown ft Depth to Water Unknown It Depth of Casing Unknown ft bgs DESTRUCTION SPECIFICATION >}tj L r tis7�� X Sealing Material from ^' It bgs to ° ft bgs Filler Material— from It bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyIt ❑ without projectile ❑ Other Nrel:rac^ig diar^Cer c 8 ro perfora7om neeced to plan tor. Sealing Material 17 Neat Cement(94 111 bag/5-6 gal wafer)❑ Sand Cement sack mbY7 gal water f: Bentonite Pellets O Bentonite(20%solids) F1 Manufacturer Spec%solids % Name Ll Specs on File Specs Submitted Placement Method Pumped ❑ Free Fall El Other Trrmie Pipe grout to surface after estab5shing boltorn of well Seal Completion i I Complete with Mushroom Cap ft bgs RI Complete to Existing Surface Pad MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS,CALL(209)953-7697 FOR INSPECTIONS DEPARTMENT USE ONLY �I ,1 Application Accepted By---=/� Date_ 1 Z ZA, Area t, > t1 -1 �^t Destruction Inspection By Date Employee ID# COMMENTS Vt 17 C-uCC>A'� �� MVNT Eo Sg PE SG Received Chectc#1 Amount Date Permit/ Invoice# Fq�Tlf� CO Codes Info By Cash Remitted Service Request# l�ry � 3 � �.� V �r a 4T aRr� Nr EHO 43-08 : 1�(I }1 /)U�/'/l WELL DESTRUCTION PERMIT 111230