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ti WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑Yes ®No V SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS F Street South Of Waterloo Road CITY/ZIP Stockton,CA 95205 v CROSS STREET Sierra Lane APN PARCEL SIZE LAND USE APPLICATION# � OWNER PG&E/Tommy Edwards PHONE 661-330-2691 OWNER ADDRESS 2600 Camino Ramon CITY/STATE/ZIP San Ramon,CA 94583 �V alms FI CONTRACTOR Cascade Dr 11 LLP PHONE 916-638-1169 CONTRACTOR ADDRESS 3000 Duluth Street CITY/STATE/ZIP West Sacramento,CA 95691 �J L; �e C-57 WELL DRILLING LICENSE NUMBER 938110 EXPIRATION DATESept.30th,2019 V C' PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP L1. ® C-57 Well Drilling License Number 938110 Expiration Date 9/30/2019 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 I&] Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom IN Gravel Pack ❑ Uncased ❑ Other Coke Breeze Well Log copy attached ❑ Yes ® No Grout Seal ❑ No M Yes 90 ft below ground surface(bgs) Hole Diameter 8 inches Well Conductor Casing❑ Yes ZI No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 2 inches Total Depth 122 _ It Depth to Water_ ft Depth of Casing 122 ft bgs DESTRUCTION SPECIFICATION Sealing Material from 0 ft bgs to 122 ft bgs Filler Material- - from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile ❑ Other Sealing Material eat Ceme 4 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(20%solid acturer Spec%solids__% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete with Mushroom Cap 5 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. 1I MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ��1• g� CONTRACTORS SIGNATURE 7it��/�'�l TITLE VP Operations DATE 04/17/2019 P�6r��1��I4e® — I _ __ — — — AfgY ®y 'SAA1,,o ?D19 l� H IRO��N COU -- p pq� ��Y - I _ P'1 MENT USE ONL 1,71q Application Accepted By Date'JG /(- Area Destruction Inspe ion B Date I Employee ID# COMMENTS L \4" CkAC _ PE SC Received Amount Date Permit/ Invoice# Well ID# Codes InfPy– -17—ash Remitted Service Rvquest# 44M 1,122,22 4 10 S1,1 -7 19 EHD 4308 WELL DESTRUCTION PERMIT revised 4/14/18