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07/26/2019 10:07Canepa & Sons (FAX) P.002/003 • WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ❑No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1859 East MaxeltOn Avonuo-STOCKTON CA 9620E-6232-(209)46E-3420 NON-REFUNDABLE PERMIT /) CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADOREasa��s 5 n1#4d/TATkh-A }CITY/ZIP 7 J CROSS ST/R,E/EIy�NlT�N/1—_/�_'1/_� APN2A1& /0'-22P-1904ARCEI.SI9,e&�LAND +C APPLICATION# o OWNER /'l ,N /J�CIJ�S�qPHONE OWNER ADDRESS�_ .7 S� /•r 0-4•R r"t-UAC A CITYISYAYe/ZIP l !�0 - �9 S 3 7,(0 - CONTRACTOR CANEPA AND SONS,INC. PHONE (209)332-1136 CONTRACTOR ADDRESS 14384 CUESTA COURT CtYY/SYAYs./21p SONORA,CA 95370 C-97WDLL DRILLING LICENSE NUMBER, 425749 ExPIRATION DATE 07/3 1/2020 PERFORATION CONTRACTOR PHONE PERPORAYION CONTRACTOR ADDRESS CITYISTATG/ZIP ❑ C-57 Well Drilling License Number Expiration Dale Bureau or 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 SherltFCoroner Explosives Application and Permit Liccnsc Number Expiration Date Ca:ifomia Occupational Safety Health-Blaster License Number Expirslion Date REASON FOR DESTRUCTION ❑ Dry ❑ Replaccmeni Well ❑ Caved In ❑ Pit Well Q Inactive E3•� � Detected/Suspected Well Water Contaminanya) r_ Adjacent property With contamination(Address) Known Soil/Water contaminants w adjacent properly EXISTING WELL CONSTRUCTON_DETAILH ❑ Open Bottom ❑ Growl Pack ❑ Uncasod ❑ Olhor Well Log copy artachod O Ye; P(I No Grout Seal O No ❑ Yea R below ground surface(bgs) Hole Diameter Inches Well Conductor Cealn'', Yee 13 No Depth of Conductor Casing it bgs Diameter of Conductor Casing Inchos Well Casing Dlamcter -lnchea Total Depth_LC,20_R Depth to Water I&ftX R Depth o1 Casing KnIL R bge RE - CTTON SPRCfPiCwtt N Scaling Material fromICZft bgs to—&—h bgs Filler Material from rt bgs 10 ft bgs A Well casing to be perforatad by ona of tho following methods: from ft bgs W ft bgs A ❑ Mills Knife Number of cuts every ft and I or AF&& Nr ❑ Explosives❑ Detonating cord ❑ With projectiles every R ❑ without projectile r ❑ Detonating cord and boosters O With projectiles every ft Cl wlthout projectile O O other �`__ `/ 3 Sealing Materiel Neat Cement(84 Ib bag/5-5 gar water) Sand Comont sack mix/7 gal water Benton1w Pew, Bentonite(2011 solids) facturer Spec%solids Name Specs on File Space Submitte Placement Method umped Fr a Fsll Other y �R�U/N�.' Seal Completion Complatc with Mushroom Cap _ft bgs Complete to Existing Surface Pad N O I HEREBY CERTIFY THAT I PREPARED IS APPLICATION AND THAT THE WORK JOU QN COUNTY ORDINANCES. M� I STATE LAWS, RULES AND REGULATIONS. I ALSO CERTIFY LL BE TNE N HATMYCREQUIRED ELICENSE WITH IS OFpAR M Njry CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION I MU. E HO AE N (�]I�Cj�E REQUIRED F INSP CTIO S CONTRACTORS SIGNAYURE -" TITL DATE i t i I I 1 1 1 1 I I. iI ! I y�_ -1 RECEIVE U . 1 JUL 2 6 2,019 I _ ' . I_ .I I _I I l l I I ONI�ILN' I,- 1L IILAL-1 --.j -I-_--,I—----i I ....._L ,__I_ .. ,_.J._—t..._.I_...1... i. L. .. L................._ VZT1\1LNT .. ........... :i... - _I....... -- — is � _I �,,,:,.; � .ILC J _L. ! i.. ... I SEP RTMENT USE ON Y l Appiicatlon Accepted By gemDate htl> Area r' Destrucdon Inspection By Data Employee ID COMMENTS PE SC Received CheekW Amount Permit] odes Info B ash Bernin9d Date Scrvicc Rc ucst# Invoice# WelllRk 501_- l'20l 'l_ �" ;R e c e I v e d T1 m e os J u l, 26, 2019 10 : 0 3 A M N o, )3 1 IJ � (�J`(J� WELL DESTRUCTION PERMIT I.--- Y V - JJJ rovlsod an All 8