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a E <br /> JA E -0FY <br /> �, UI an Joaquinpunty <br /> Environmental Health �epartmen <br /> N i SITE <br /> I a 600 East Main Street, Stockton, CA 95202-3029 ti�1�t _ 8 2008 MITIGATION <br /> 1! (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.or�ehd <br /> �77 <br /> ' P / ENVIRGnI(�FN7H UNIT IV <br /> Well Permit Application *Fr �l,N <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tvif TISERViCES <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 omp�1,nc�eh San <br /> Joaquin County Development Title,Chapter 9-111155.3 and the Sjandards of San Joaquin County Environmental Health Department. <br /> WELL Location -{l/J�,[ �� 917 LODI Assessors �"/ <br /> CityPROZiP Parcel# U/ <br /> OOwnerERTYSan Joaquin County 1810 E. Hazelton Ave. <br /> Address Stockton 55201 <br /> CityZIP Phone# 209-468-3058 <br /> C•57 Contractor Mitchell Drilling gddress 7900 Myrtle Ave. 672617 <br /> CityEureka ZIP 95503 Lie# Phone#707-444-9040 <br /> Consultant/Sub Cntr A.G.E. 837 Shaw Rd. Stockton <br /> Address City Lic# 680227 209-467-1006 <br /> ' Phone# <br /> GIS Coordinates:X y , <br /> Township Range Section <br /> WORK TO BE PERFORMED: ^ ^ <br /> 0 NEW WELL/BORING (cPT,GEOPROBE,HYDROPUNCHAND-AUGER,OTHER-) 4DESTRUCTION (choose type below) <br /> DWELL „ J, r <br /> 0 %� H �rf�r/C D OVER-BORE.. DIAMETER <br /> 0 SOIL BORING# <br /> 0*Other � ?a#PRESURE GROUT <br /> See Work Plan, dated 17 March 2008. Abandon CMT well MW-01'00UT I SP�CATIONSportland Type II w <br /> COMMENTS: �\ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ <br /> 0 EXTRACTION 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL D OTHER: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: EMIE TYPE TO BE USED: GAUGERS p HOSE <br /> 0 SOIL BORING D Yes p No (NOTE: <br /> TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O HAND AUGER GROUT SPECIFICATIONS � <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE (� <br /> CONDUCTOR CASING PROPOSED <br /> COMMENTS: (if YES,list specifications in comment section) �U" <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@0 Title/Company PROGECT GEOLOGIST/A.G.E. <br /> Print Name TIMOTH J. CUELLAR 04/08/08 <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: l � 08 � p <br /> Application Accepted By Date Issued U ��I <br /> Grout Inspection By Area <br /> Date Final Inspection Date —21!57-10 F, <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> k , 7.419 SR# D 3q <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dor <br /> EHD 29-02-001 WEB <br /> 9/11/2007 i7 �Opr) <br /> //'� orp 54 <br />