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r �oP' 'I�•co <br /> San Joaquin Colin ty1J �ED FILE COPY Z <br /> Environmental Health Depart8 2008 SITE <br /> 2-3 <br /> 600 East Main Street, Stockton, CA 9520 29 <br /> (209)468-3449 Fax: (209)468-3433 Web: wwv atjk& T HEALTH MITIGATION <br /> RcrFbtii�`Q PERMI /SERVICES UNIT IV <br /> Well Permit Application (J <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPQ c,,e 5 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made n compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 14659 N. Thornton Rd. Capitol Ave. Assessors <br /> WELL Location Cross Street Thornton Rd. City LODI Zip 95245 Parcel# 055-150-25 <br /> PROPERTY Richard Bokides P.O. BOX 1411 WOODBRIDGE 95256 <br /> Owner Address City Zip Phone#209-367-9330 <br /> Mitchell Drilling 7900 Myrtle Ave. Eureka 95503 672617 707-444-9040 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Lic# Phone#Stockton 680227 209-467-1006 <br /> �,pG <br /> GIS Coordinates:X �• 1 ,Y Z� J t/ ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL I BORING (CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) YgDESTRUCTION (choose type below) <br /> aSOIL BORING# 40VER-BORE. DIAMETER 8/10/12-INCH <br /> 11 WELL# Q PRESSURE GROUT <br /> O'other GROUT SPECIFICATIONSportl and Type II <br /> COMMENTS: See Work Plan, dated 17 March 2008. Abandon wells MW-7/1t/12/14/15/16/17/18 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_ <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL p PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> a AIR SPARGE/OZONE u PUSH POINT(GP orCPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a 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 <br /> D P ^I ny- Title/Company PROGECT GEOLOGIST/A.G.E. <br /> � lMK/� <br /> Print Name TIMOT . CUELLAR Date 04/08/08 <br /> DEPARTMENT USE ONLY <br /> ,,���� / Zc7 S� <br /> SITE MAP IN UNIT IV FILE, ADDRES to � /,f/- r� Va/v <br /> WORK PLAN DATED: / 6 f <br /> Application Accepted By Date Issued —Z- 6 FA,,a DVK <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �D SR# Q <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encr ment doc_ <br /> ERD29-02-001 WEB �E <br /> 9/11/2007 <br />