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WELL DESTRUCTION PERMIT 4 PUBLIC WATERSYSfFJt'1[3 Yes] No ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 t WEBER Ave 3-FL-STOCKTON CA 95202-(209)466-3420 NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Crry/ZIP TRACY . 95304 JOBADDRFSS 8338 W. .LINNE RD. ^J/ � y > CROSSSTREET W. DEPOT MASTER DR_ APN0'2t�3O PARCELS=JL-0 LAND USE APPLICATION# OWNER BILL PRIOSTE PHONE 833-9945 OWNERADDRESS 8338 W. LINNE RD. CITY/STATE/ZIP TRACY; CA 95304 CONTRACTOR HENNINGS BROS. DRILLING CO., INC. PHONE 545-1185 CONTRACTOR ADDRESS3525 PELANDALE AVE. CITYISTATE/ZIP MODESTO CA 95355 CK C-57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS Crry/STATEIZIP CD( C-57 Well Drilling LlcenseNumber 290813 Expiration Date 5-31-08 11 Bureau of Alcohol,Tobacco'and Firearms-Users of High Explosives License Number Expiration Date r`r ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date ` ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date C3 California Occupational Safety Health-Blaster License Number Expirntion Dau [3 Dry 13ReP Replacement Well ❑ Caved In ❑�Pit Well XX Inactive C3 Test Hole REASON POR DESTRUCTION - ! Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ff Gravel Pack ❑ Uncased ❑ Other Well Log copy attached IXXXA ❑ 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 E Well Casing Diameter 6't - inches Total Depth 80 ft Depth to Water ft Depth of Casing ft bgs 4 DESTRUCTION SPECIFICATION bgs Sealing Material from 0 fl bgs to 80 ft bgs Filler Material from fl bgs to ft Well using to be perforatedby one of the followine methods: from ft bgs to ft bgs ❑ Mills Knife Number of cuts every ft and/or ❑ Explosives ❑ Detonating cord ❑ with projectiles everyfl ❑ without.projectile ❑ Detonating cord and boosters ❑ with projectiles everyft ❑ without projectile ❑ Othcr Sealing Material [3 Nest Cement(941b bag 15-6 gal waler) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite Pelkte 1X Bentonite(20%solids) ❑ Manufacturer Spec°/solids % Name ❑ Specs on File ❑ Specs Submitted Placement Method jX Pumped ❑ Free Fall ❑ Other ft b Complete to Existing Surface Pad Seal Completion ❑ Complete with Mushroom Cap bgs I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITJOAQUIN COUNTY H SAN IS CURRENT AND ACTIVEWITHTHE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TINANCM STATE LAWS,AND RULES AND REGULATIONS. I ALSO B T I AM IN COMPLIANCEFY THAT my REQUIREDLICENSE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQ14RED FOR INSPECTIONS CONTRACTORS scnwruRE �1L0 trLE SUPERVISOR DATE6-22-07 J- '-4.4 ._'_t' u � 7 I ECE VNp- � .._ f— r � 1 �I �' r .., �-- ♦• • �.._I ��,.. Sgt,1 JOAQUI . a _ y Application Accepted B Date Area Destruction Inspection By Dau Employee ID# COMMENTS PE SC Received Ch Amount Date Permit/ Invoice# WellID# Codes Info BY Cash Remitted service Request# ' $ s s sa. l7 -to wal Daae-.P—. EHD 43-02-OON 12712005