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WELL DESTRUCTION PERMIT #17933 PUBLIC WATER SYSTEM ❑Yes ❑No 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 137 AirportWay CITY/ZIP Manteca 95337 CROSSSTREET West Yosemite Avenue APN 19817026 PARCELSIZE e,42,S,LAND USE APPLICATION# OWNER Shaan Investment,LLC PHONE 209-855-6637 H N OWNER ADDRESS 964 Shortland Circle CITY/STATE/ZIP Manteca,CA 95337 CONTRACTOR Cascade Drilling PHONE(916)638-1169 CONTRACTOR ADDRESS 3000 Duluth Street CITY/STATE/ZiP West Sacramento,CA 95691 C-57 WELL DRILLING LICENSE NUMBER 938110 E%PIRATION DATE 09/30/2019 PERFORATION CONTRACTOR McMillan Well Services,LLC PHONE PERFORATION CONTRACTOR ADDRESS 12302 Andes Ave CITY/STATE/Zlp Bakerfield,CA 93312 ❑ 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 9201 Expiration Date 4/5/2021 REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved in ❑ Pit Well M Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) MTBE Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property EXISTING WELL CONSTRUCTION DETAILS C4 Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes 0 No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches Well Conductor Casing❑ Yes 14 No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches Well Casing Diameter 5.5 inches Total Depth 83 ft Depth to Water Unknown ft Depth of Casing 72 ft bgs DESTRUCTION SPECIFICATION Sealing Material from Total Depthft bgs to 0 ft bgs Filler Material None from ft bgs to ft bgs Well casing to be perforated by one of the following methods: from 0 it bgs to 83 ft bgs ❑ Mills Knife Number of cuts every ft and/or Q Explosives❑ Detonating cord ❑ With projectiles every it ❑ without projectile iia Detonating cord and boosters M With projectiles every 10 it ❑ without projectile ❑ Other Sealing Material ViNeat Cement(94 lb bag/5-6 gal water) Sand Cement sack mix/7 gal water Bentonite Pellets Bentonite(201%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Comp ele with us room Cap it bgs Complel to xlstln u ace a 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. MI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS A CONTRACTORSSIGNATURE rC� �N TITLE VP Operations DATE 03/29/2019 if S.qy� 919 My, 10 by�o� 19 FpgRHrq�N� MFNT E i Opp :JP I n/may/ PA M E N T USE O L Application Accepted By -44/�f'((O�.J Date Area Destruction Inspe n ByMgjjiib l Diote.. Employee ID# COMMENTS D to K At 36 11111--e- PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info EII Zash Fiernitted Service Re uest# EHD 43-08 WELL DESTRUCTION PERMIT revised 4/14/18