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WELL DESTRUCTION PERMIT � + PUBLIC WATER SYSTEM El Yes ❑No ♦ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT 'BALL 209 953-7697 FOR INSPEGTK':..: EXPIRES 1 YEAR FROM DATE ISSUED JoBADDRESS2829 W Was inton Street c,,,,q,,Stockton,. CA 95201 F CROSSSTREET S Stork Rd APN �� PARCEL$ LAw S APP O # C Port of Stockton (Steve Escobal:PlONE g- OWNER ZU �-� � (7 C/� rn OWNERADDRESS Washington On Street CITY/STATE0, Stockton, A 95201 CONTRACTOR u r v i a n c Drilles Inc. PHONE 20 — —3 55 CONTRACTOR ADDRESS POBOX CITY/STATERIP Linden, CA 95236 C-57 WELL DRILLING LICENSE NUMBE EXPIRATION DATE 7/31 /19 PERFORATION CONTRACTOR n/a PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATE21P ❑ 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 1ff Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ® Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) PAY" ` Known Soil/Water contaminants at adjacent property AIT EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom IN Gravel Pack ❑ Uncased ❑ Other ECEIVE® Well Log copy attached ❑ Yes B No Grout Seal ❑ No ❑ Yes it below ground surface(bgs) Hole Diameter inches �� Well Conductor Casing C3 Yes 13 No Depth of Conductor Casing ft s Diameter of Conductor Casing inches 0 5 2019 Well Casing Diameter f r inches Total Depth 1 z 2 ft Depth to Water , ft Depth of Casing ft b s DESTRUCTION SPECIFICATION EQ1 OAQUI COUNTY Sealing Material fromy it bgs to�ft bgs Filler Material �/�w from ft bgs to A ENTiL Well casing to be perforated by one of the following methods: from ft bgs to ft bgs H')EPAR71►MENT ❑ Mills Knife Number of cuts every It and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material C<eat Cement(94/b bag/5-6 gal water Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%S51—I aclurerSpe, o solids_% Name Specs on File Specs Submitted Placement MethodPumped Free Fall Other Seal Completion Complete vn ushroorn Cap ft bgs Complete to Existing Surface Pad 1 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. 1 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. IMUM 4 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS n CONTRACTORS SIGNATU 'A TITLE DATE Y� \ ER RTMENT USE O tt (® '(—` ,1 Application Accepted By J Date F Area vJ Destruction Inspection By Date Employee ID# COMMENTS PE SC Received Chec Amount Date PermIV Invoice# Well ID# Codes Info Romitled Service R quest# EHD 4308 WELL DESTRUCTION PERMIT 10!5/07