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WELL DESTRUCTION PERMIT <br />C1685 Destruction PUBLIC WATER SYSTEM ❑Yes El No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 Fast Hazelton Avenue - STOCKrON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDREss NE Corner of W.Washington and Ventura Ave <br />CITY21P Stockton, 95203 <br />CROSS STREET Ventura Ave APN ROW <br />PARCEL SIZE <br />USE APPLICATION # <br />I S 0 5 <br />_LAND <br />5 1 <br />OWNER PG&E Arne <br />PHONE <br />OWNER ADDRESS 3965 Occidental Road <br />CITYISTATE21P <br />Santa Rosa, CA 95401 <br />CONTRACTOR Gregory Drilling <br />PHONE 530-565-6289 <br />CONTRACTOR ADDRESS 14112 452nd Ave SE <br />CITYISTATEIZIP <br />North Bend, WA 98045 <br />C-57 WELL DRILLING LICENSE NUMBER 1007649 <br />EXPIRATION DATE <br />1/31/23 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />F4 C-57 Well Drilling <br />License Number 1007649 <br />Expiration Date 1-31-23 <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiration Date <br />CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />Expiration Date <br />California Occupational Safety Health - Blaster <br />License Number <br />Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well <br />N Inactive ❑ Test Hole <br />Detected / Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property <br />EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased gl Other <br />Well Log copy attached ❑ Yes IN No Grout Seal ❑ No IN Yes 55 It below ground surface (bgs) Hole Diameter 6 inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 1 inches Total Depth 160 ft Depth to Water ft Depth of Casing ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to 160 ft bgs Filler Material Neat Cement <br />Well casing to be perforated by one of the following methods: from <br />❑ Mills Knife Number of cuts every ft and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every ft ❑ without projectile <br />from 0 ft bgs to 160 ft bgs <br />It bgs to ft bgs <br />lkher Well will be overdrilled with 7.25" Sonic casii <br />Sealing Material I Neat Cement (94 Ib bag 15-6 gal water) <br />Bentonite (20% solids) Manufacturer Spec %solids_ <br />Placement Method Pum ed Free Fall <br />Seal Completion Complete with Mushroom Cap <br />id Grouted via trimmie pipe from the bottom up <br />Sand Cement sack mix / 7 gal water <br />% Name Specs on File <br />Other <br />it bgs Complete to Existing Surface Pad <br />Bentonite Pellets <br />Specs Submitted <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORSSIGNATURE� TITLE VP DATE 7-9-23 <br />4, <br />ra <br />Application Accepted By _ <br />Destruction Inspection By <br />I? <br />DEPARTMENT USE ONLY <br />W W,ash�t`c3t <br />Area I `� q <br />molovee ID# in < <br />Eq yM� <br />ccvl/ <br />Fp <br />�L Vj� U/NC <br />Ty IARNo `Nry <br />PE I SC I Received Check#/ I Amount <br />Date I Permit/_ Invoice # Well ID# <br />EHD 43-08 (W' " - _ / ' ' - /2,F c.�� , 2 WELL DESTRUCTION PERMIT <br />revised 4/14/18 V ` `-t' J <br />I"Ov <br />