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• COPY <br /> ILE <br /> Ran Joaquin County rr-�-� p� <br /> y �y` Environmental Health Departmen>�IS���U SITE <br /> 600 East Main Street, Stockton, CA 95202-30292QSaMITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/e4VR _ �JNIT IVLrFsdN Well Permit Application ENVIRONMENT HEALT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPERMIT/SERVtM' <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 14749 NTHo rnton Rd Capitol Ave. LODI 95245 Assessors 055-150-26 <br /> N.WELL Location Cross Street Thornton Rd. City Zip Parcel# <br /> PROPERTY Andy Zarakani P.O. Box 1036 Tracy 95379 209-914-3386 <br /> Owner Address City Zip Phone# <br /> Mitchell Drilling 7900 Myrtle Ave. Eureka 95503 672617 707-444-9040 <br /> C-57 Contractor 9 Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton.Lid/ 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (OPS,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) x4DESTRUCTION (choose type below) <br /> G SOIL BORING# n OVER-BORE. DIAMETER <br /> LL 11 UPRESSURE GROUT <br /> *Other GROUT SPECIFICATIONSportl and Type II <br /> COMMENTS: <br /> See Work Plan, dated 17 March 2008. Abandon well MW-13 `\ <br /> „C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL U PVC G OTHER: <br /> a VAPOR u MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: H AUGERS a HOSE C <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x � P �A Tille/Company Date PROGECT GEOLOGIST/A.G.E. <br /> PdntName � IA..W� <br /> TIMOTHY J. CUELLAR 04/08/08 — <br /> DEPARTMENT USE ONLY 2-9, S� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Il W <br /> WORK PLAN DATED: 41 / /d' <br /> Application Accepted By Date Issued Un Area Q 6 <br /> Grout Inspection By Date Final Inspection By ale C <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Pt W ' Z q( GA ;S•o€ sR# 05Yl6L <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encro ment doc_ <br /> EM29-02-001 WEB Lt,GGtA7 � S•7-OP <br /> 9/11/2007 <br />