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WELL DESTRUCTION PERMIT PUBLIC WATER SYSTEM ❑ Yes ® No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-RFFIINnAR1 F PFRMIT (:AI 1 19091 Si53-7897 Fns I`J5PF^TI()rJH FXPIRFS 1 YFAR FRnM nATF ISS[fFD JOB ADDRESS 920 West Frewert Road CITY/ZIP LalhroP, Califome. 95330 31A CROSS STREET Interstate 5 APN 191-260-22 PARCEL SIZE acres LAND USE APPLICATION # PA 1200011 OWNER James E. Sanchez PHONE 209-840-2883 OWNER ADDRESS 8700 Woodward Lake Drive CITYISTATE/ZIP Oakdale, California. 95361 CONTRACTOR Maggiora B.S. Drilling, Inc. PHONE 831-724-1338 CONTRACTOR ADDRESS 595 Airport Boulevard CITYISTATEI7P Watsonville, Callfomia, 95078 C-67 WELL DRILLING LICENSE NUMBER 2$99$7�F-`� EXPIRATION DATE 9/30/2021 PERFORATION CONTRACTOR McMillan's Well Service, LLC PHONE 916-761-5224 PERFORATION CONTRACTOR ADDRESS 12302 Andes Avenue CITY/STATEIZIP Bakersfield, CA, 93312 ❑ C-57 Well Drilling License Number 2957 Expiration Date 9 /3 012 02 1 Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number 9LA1 9�3-1A-02728 Expiration Date OV0112021 CHP Hazardous Material Transportation for Explosives License Number N/A Expiration Date N/A San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number 20-01 Expiration Date 02/11/2020 California Occupational Safety Health - Blaster License Number 8201 Expiration Dale 04/05/2021 REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ® Inactive ❑ Test Hole Detected / Suspected Well Water Contaminant(s) None Adjacent property with contamination(Address) None Known Soil / Water contaminants at adjacent property None EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased © Other Unkno. Well Log copy attached ❑ Yes M No Grout Seal ❑ No ❑ Yes U,kn— it below ground surface (bps) Hole Diameter Unknown inches Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing Unknovm It bgs Diameter of Conductor Casing Unknown inches Well Casing Diameter 18 inches Total Depth Unkno%%m ft Depth to Water Unknown ft Depth of Casing Unknown ft bgs DESTRUCTION SPECIFICATION Sealing Material from _S _ft bgs to Unknown ft bgs Filler Material Native Soil from 0 ft bgs to S 'b93 T..] T q or Well casing to be perforated by one of the following methods: Explosives from 20 it bgs to wdI ft bgs ❑ Mills Knife Number of cuts every ft and / or 0 Explosives ❑ Detonating cord ❑ with projectiles every ft ❑ without projectile ® Detonating cord and boosters ❑ with projectiles every It El without projectile ❑ Other Sealing Material Neat Cement (94 ib beg/5-6 gal water) Sand Cement 11 sack mix /7 gal water Bentonite Pellets Bentonite (20% solids) Manufacturer Spec % solids_ % Name Specs on File Specs Submitted Placement Method Pumped Free Fall Other Seal Completion Complete wilh Mushroom Cap 5 R bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 1st UUNt IN ALLUKUAN-t WI IH DAN 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. DEPARTMENT USE ONLY Application Accepted By Date Area Destruction Inspection By „� _ Date A31111V Employee ID# COMMENTS PE SC Received Check#/ Amount Date PermiU Invoice # Well ID# Codes Info B Cash Remitted Service Re uest# �1,� l 5 3 EHD 4308 WELL DESTRUCTION PERMIT revHed 4114„8 /i--'�O741l 'IVND 2020 COUNr NT,4� Y 'TMENr