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WELL DESTRUCTION PERMIT a PU►.�/%7ER SYSTEM [:]Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IIEPT 1868 East Hazelton Avenue—I CKTON CA 95205-6232-(209)468-3420 1 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2905 West Benjamin Holt Drive CrrY/ZIp Stockton 95207 y CROSS STREET Plymouth Road APN City ROW PARCEL SIZE_LAND USE APPLICATION# C OWNER City of Stockton-Swenson Park Golf Course PHONE OWNER ADDRESS 425 North EI Dorado Street Crrr/STArE21P Stockton,CA 95202 CONTRACTOR National EWP PHONE 530-419-7300 CONTRACTOR ADDRESS14110 Cacheville Road CITY/STATE21P YOIo,CA 95695 C-57 WELL DRILLING LICENSE NUMBER953646 EXPIRA-nON DATE 10/31/14 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS Cry/STATE/Zip ❑ 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 California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well X Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s)Historically:Hydrocarbons and hydrocarbon derivitives Adjacent property with contamination(Address)ARCO 2133;2908 West Benjamin Holt Drive,Stockton,CA 95207 Known Soil/Water contaminants at adjacent property Historically:Hydrocarbons and hydrocarbon derivitives EXISTING WELL CONSTRUCTION DETAILS MW-6 and MW-8 Well Log copy attached X Yes ❑ 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 Diameter Inches Total Depth ft Depth to Water ft Depth of Casing ft bgs DESTRUCTION SPECMCATION Pressure Grout(see Well Destruction Details Table) Sealing Material from T.D. ft bgs to 3 it bgs Filler Material(dry-sack concrete) from 3 It bgs to–1 it bgs Well casing to be perforated by one of the following methods: from It bgs to It bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating card and boosters ❑ with projectiles every It ❑ without projectile ❑ Other Sealing Material I Neat Cement(94/b bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solids) Manufacturer Spec/solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap from 3.5-3 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 REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE DATE + + a��p•-- .it{. F + .. i- p. r + ,. .. j s r fi .F... .I- +" DEPARTMENT USE ONLY Application Accepted By Date Area Destruction Inspection By Date Employee ID# COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# invoice# Well ID# EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07