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WELL DESTRUCTION PERMIT r PUBLIC WATER SYSTEM ❑Yes SAN JOAQUIN'COUNTY ENVIRONMENTAL HEALTH DEPT 1866 East Hazelton Avenue-STOCKTON CA 95205-6232//-- ('(209)468-3420 NON-REFUNDABLE PERMIT I CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS_ -TO xJ-r N• JQc T Yd CITY/LP S CId00 5215 y CROSS STREET N Of E Fairchild Rd APN 129 J9n-94_PARCEL SIZE610LAND USE APPLICATION# b OWNER Chinchiolo Stemlit Packing C-o Todd PHONE 209-986-2808 OWNER ADDRESS 4799 N Jack Tone Rd CITY/STATE/ZIP Stockton CA 95215 y CONTRACTOR Hennings Bros. Drilling Co Inc PHONE 209-545-1165 CONTRACTOR ADDRESS 1930 Ladd Rd CITY/STATEIZIP Modesto CA 95356 C57 WELL DRILLING LICENSE NUMBER 290813 EXPIRATION DATE 05-31-2018 PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITYISTATEIZJP IR C-57 Well Drilling License Number 290813 Expiration Date 05-31-18 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 12 Replacement Well ❑ Caved In ❑ Pit Well ❑ 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 ❑ Gravel Pack ❑ Uncased R Other N/A Well Log copy attached ❑ Yes R No Grout Seal ❑ No ❑ Yes_it below ground surface(bgs) Hole Diameter N/A inches Well Conductor Casing ❑ Yes R No Depth of Conductor Casing N/A it bgs Diameter of Conductor Casing N/A inches Well Casing Diameter 12 inches Total Depth 348 It Depth to Water N/A It Depth of Casing N/A ft bgs DESTRUCTION SPECIFICATION Sealing Material from n ft bgs to 1 nn ftbgs Filler Material Gravel anrf sand from inn ft bgs to 349 it bgs Well casing to be perforated by one of the following methods: from it bgs to it 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 It ❑ without projectile ❑ Other Sealing Material Neat Cement(94 lb bag/5-6 gal water) Sand Cement 10.3 sack mix/7 gal water Bentonite Pellets Bentonite(200Y.solids) anufacturer Spec%solids_% Name Specs on File Specs Submitted Placement MethodPumped Free Fall Other Seal Completion Complete ushroom Cap d 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. MINIMUM 24 HOUR ADVANCE NOTICE RE UIRED FOR INSPECTIONS CONTRACTORS SIGNATURE - , (� TITLE 'V-• �. DATE l 17 lotRFS MEN FD NIMP �T RONMENTON HoEP,gRT,VENT o DEPARTMENT USE ON Y P, Application Accepted By - Date ( Area Destruction Inspection - I Date t e Employee ID# COMMENTS c4, © ^ 4kA 4. Igo VX11 w" v i 100 to WVq lox PE SC Received Amount Da Permit/ Invoice# Well ID# Codes Info B /Cash Remitted rvice Re uest# Irlpl-El 1A0 v -7 EHD 43-08 WELL DESTRUCTION PERMIT 10/5/07