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`.LLL DESTRUCTION PERMF( SCANNED 4 r PUBLIC WATER SYSTEM p Yes No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-ST C 2 420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRE$ Y E SUED JOB ADDRESS G CITYIZIP Manteca 3 3 a CROSS STREET French Carnp Road AP 'O _p 4`3L > PARCEL SIZ�a AND USE APPLICATION# OWNER Wilbur Ellis Co. PHONE 982-5400 M OWNERADDRESS 13771 South Prescott Road CITY/STATE/ZIP Manteca ,, CA 95336 CONTRACTOR Clark Well , Inc. PHONE 209-462--7676 CONTRACTOR ADDRESS XOZSX 2024 East Charter Way CITY/STATE/ZIP Stockton, CA 95205 C-57 WELL DRILLING LICENSE NUMBER 371560 EXPIRATION DATE 04/06 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP ❑ C-57 Well Drilling License Number Expiration Date i ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date O 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 [3 Caved In ❑ Pit Well CK inactive ❑ Test Hole Detected/Suspected Well Water Contaminants) Adjacent property with contamination (Address) i Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTR UCTION DETAILS Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes Ak No Grout Seal b 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 12 inches Total Depth 87 ft Depth to Water 38 ft Depth of Casing ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to 87 ft bgs Filler Material from ft bgs to ft bgs Well casing to be perforated by one of the followin methods: from ft bgs to ft bgs Mills Knife 4 Number of cuts every 1 ft and/or Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile El Other Sealing Material ❑ Neat Cement(94 lb hag/5-6 gal water) f!i( Sand Cement ,rack mix 17 gal water ❑ Bentonite Pellets Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fall ❑ Other Seal Completion 7K Complete with Mushroom Cap F ft bgs ❑ Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINA CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE l5 CURRENT AND ACTIVE WI T E4CALIFNTRACTORS S TE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALLWORKERS COMPENSATION MI N CE EQUIRED FOR INSPECTIONS CONTRACTORS SIGNATURE TITLE Sec—Tres DATE 13 Jan 06 7. - � s �.. ' 4 � s 11 ^g� �. _ JA 20(36 J. �C,,� 6r �t7tfQ"C"C7 NVIHONMENTAL i t --.�.- �—....$-1EALTDI~PARTMEN7 .a.. . s � i �• i 4 i � § t g '� DEP RTMENT USE ON Y Area Appiicatilon Accepted By Date �� (9 i Destruction Inspection By Date �. Employee ID# COMMENTS PE 'F SC Received 1. Ch Amount Permit/Codes Info B m Cash Remitted Date Service m nest# Invoice# Well ID# S GLL 3 7 , , 3 Ak u5 L ; EHD 43-02-008 112712005 Well pcstruction Permit