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WELL DESTRUCTION PERMIT <br />f PUBLIC WATER SYSTEM ❑ Yes [N No <br />SAN JOACI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON -REF DABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YFAR FRnM nATF ICCIIFn <br />JOB ADDRESS N. Union Rd. <br />CITY/ZIP Manteca 95336 <br />CROSS STREET N. of Lathrop Rd. APN 204-100-56 <br />PARCEL SIZE - LAND USE APPLICATION # <br />OWNER Nunes Family Properties, LP <br />PHONE 209-471-4538 Art Nunes <br />OWNER ADDRESS 1463 Moffat Blvd., Ste. 5 <br />CITY/STATE/ZIP Manteca, CA 95336 <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. <br />PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1930 Ladd Rd. <br />CITY/STATE/ZIP Modesto, CA 95356 <br />t( C-57 WELL DRILLING LICENSE NUMBER 290813 <br />EXPIRATION DATE May 31, 2022 <br />PERFORATION CONTRACTOR <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />6 C-57 Well Drilling <br />License Number 290813 Expiration Date 5-31-22 <br />❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number Expiration Date <br />❑ CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number Expiration Date <br />❑ California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well 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 ❑ Other <br />Well Log copy attached ❑ Yes t( No Grout Seal ❑ No ❑ Yes <br />ft below ground surface (bgs) Hole Diameter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing <br />ft bgs Diameter of Conductor Casing inches <br />Well Casing Diameter 4° steel inches Total Depth est. 150 ft Depth to Water ft Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from D ft bgs to est�cn ft bgs Filler Material <br />from ft bgs to ft bgs <br />Well casing to be perforated by one of the following methods: <br />from ft bgs to ft bgs <br />❑ Mills Knife Number of cuts every ft and/or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Detonating cord and boosters ❑ with projectiles every <br />ft ❑ without projectile <br />❑ Other <br />Sealing Material Neat Cement (94 Ib bag/5-6 gal water) Sand Cement <br />sack mix/7 gal water Bentonite <br />Pellets <br />X Bentonite (20% solids) Manufacturer Spec % solids % Name <br />Bariod-Quik Grout Specs on File Specs Submitted <br />Placement Method X Pumped Free Fall <br />Other <br />Seal Completion X Complete with Mushroom Cap 5 ft bgs <br />Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />��_�� DEPARTMENT <br />Application Accepted By �rG L—'4r <br />Destruction Inspection By <br />COMMENTS <br />USE ONLY <br />Date 3 `/ �' Area li%' 1� �F' c C,, <br />Date Employee ID# a <br />T <br />PE <br />SC Received hec <br />Amount <br />Permit/ <br />Codes <br />Info B as <br />Date <br />Remitted <br />Service Request # <br />Invoice # <br />Wel <br />4373 <br />(,1 <br />�#I�iS-' 3- 22. <br />EHD 43-08 <br />11/23/21 <br />WELL DESTRUCTION PERMIT <br />