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WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes b No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPFr_TIONS FXPIRFS 1 YFAP FRnM nATF IccilFn <br />JOB ADDRESS 15465 E. French Camp Rd. <br />cITY/zIP Ripon, CA 95366 <br />CROSS STREET N. of Louise Ave. APN 203-11-008 <br />PARCEL SIZE 2•00LAND USE APPLICATION # <br />OWNER Mothou Do <br />PHONE 209-606-7213 <br />OWNER ADDRESS 15465 E. French Camp Rd. <br />CITY/STATE/ZIP Ripon, CA 95366 <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. <br />PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1930 Ladd Rd. <br />CITYISTATE/ZIP Modesto, CA 95356 <br />b C-57 WELL DRILLING LICENSE NUMBER 290813 <br />EXPIRATION DATE May 31, 2024 <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 5-31-24 <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 6 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 q 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 6" steel inches Total Depth It Depth to Water ft Depth of Casing It bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to bottom 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 />_ <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 /b bag/5-6 gal water) Sand Cement <br />sack mix:7 gal water Bentonite <br />Pellets <br />Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name <br />Quik Grout Specs on File Specs Submitted <br />Placement Method X Pumped Free Fall <br />Other <br />Seal Completion Complete with Mushroom Cap ft bgs <br />X Complete to Existing Surface Pad <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, CALL (209) 953-7697 FOR INSPECTIONS <br />DEPARTMENT <br />—`~ <br />Application Accepted By �- <br />Destruction Inspection By <br />COMMENTS 1 J,elbf l0-� �e� I Z 1C)T I� 1'1040 f� I <br />USE ONLY <br />Date // � � c� Area �� Y (" <br />Date 5 C -QO2,,- Employee ID# /7 `7 <br />"CONN. Of.,Q-tu : \'�A . -"" N' "-h �->�(, . � - ]Y-• P1%'�IeAAF _ <br />T <br />PE SC Received Check#/ Amount D e Permit/ <br />Codes Info B Remitted Service Re uest # <br />Invoice # Q II ID# <br />140" <br />VIS <br />H 3E> Fo p 0 1 I1 ZZ <br />y DE R9�cNT 1Y <br />FNT <br />EHD 43-08 WELL DESTRUCTION PERMIT <br />11/23/21 <br />