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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes E,No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1600 W. Linne Rd. clTYraP Tracy 95377 CROSS STREET W. of Corral Hollow RdaPN 253-110-03 PARCEL SIZE RAND USE APPLICATION# OWNER Fer uson Fire/Fa . c FIqres Excay. &Demo PHONE 892-1099 OWNER ADDRESS P.O. Box 1416 11 0*5hn— / CITYISTATE/ZIP Patterson, CA 95363 CONTRACTOR Hennings Bros. Drilling Co.. Inc. PHONE 545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto CA 95356 C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE May 31, 2018 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE/ZJP IX C-57 Well Drilling License Number 290813 Expiration Date 5-31-18 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 California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well p(Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Untried EX Other unknown Well Log copy attached ❑ Yes (X No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Dlameter_- a_in s Total Depth est__2Q6 Depth to Water ft Depth of Casing ft bgs DESTRUC'T'ION SPECIFICATION Sealing Material from Oft bgs to ft bgs Filler Material from ft 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 every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets )(Bentonite(20%solids) Manufacturer Spec%solids_% Name Bariod-Quik Grout Specs on File Specs Submitted Placement Method XPumped Free Fall Other Seal Completion Complete with Mushroom Cap 4 ft bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE! 1 ED OR INSPECTIONS CONTRACTORS SIGNATURE `i 6A-/M b/ TITLE Vice President DATE Jan. 18, 2018 Y C c —�- O M _. ErrI D-E ARTMENT USE O LY A Application Accepted By Date Area c ►�'J Destruction Inspec ion By ✓1 r� Date L Employee I COMMENTS ��2 217 Gt/C j �Cp GKII T W/;k Ze Vl'7ce PE SC Received hoc Amount Date Perrot/ Invoice# Well ID# Codes Info B ash Re ittd Service Reguest# �t I 'P2 EHD 43-08 WELL DESTRUCTION PERMIT 10/5107