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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205 - (209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m JOB ADDRESS 27100 E. Flood Road CITY/ZIP Linden, CA 95236 0 a CROSS STREET ESCALON BELLOTA APN 093-290-01 PARCEL SIZE 80 LAND USE APPLICATION# O A OWNER Anthony Gandolfo PHONE OWNER ADDRESS 27100 E Flood Rd CITY/STATEIZIP Linden, CA 95236 CONTRACTOR SJC Department of Public Work PHONE (209) 468-3000 CONTRACTOR ADDRESS 1810 E. Hazelton Ave CITY/STATEIZIP Stockton, CA 95205 ❑ C-57 WELL DRILLING LICENSE NUMBER N/A EXPIRATION DATE PERFORATION CONTRACTOR N/A PHONE PERFORATION CONTRACTOR ADDRESS N/A CITY/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 ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known SodAVater contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ 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 It Depth to Water ft Depth of Casing It bgs DESTRUCTION SPECIFICATION Sealing Material from ft bgs to ft bgs Filler Material frorn ft bgs to ft bgs Well casing to be Perforated by one of the following methods: from ft bgs to it bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb beg15-6 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 ft bgs i 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. 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE FOR DOCUMENTATION PURPOSE ONLY TITLE DATE See Attached Map DEPARTMENT USE ONLY Application Accepted By:EH o leted for for eu f 'e ose only Date Area Destruction Inspection B L - Date Employee COMMENTS Site was a Crirdfral investigation initiated by The Sheriffs Office and FBI with Department of Public Works Assistance. Pit well was excavated fpr remains of victims murdered by Wesley Shermantine and Loren Herzog. PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID Codes Info B Cash Remitted Service Request# 4374 165 0.00 SR0066665 EHD 43-08 WELL DESTRUCTION PERMIT 4130/12