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o 4an Joaquin County �(_�ii.��� 1/ �� <br /> ul 1 Environmental Health Department SITE <br /> S <br /> ` 600 East Main Street, Stockton, CA 95202-3029 APR 2 2 2 TI ITE <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orATION <br /> g/eVIROh�)aiEf iT HEAI[�'INIT IN <br /> p <br /> Well Permit Application PERMff/SEI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ©IVI W 1/I l � <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 /> 6421 Capitol Ave. , Lodi CA Capitol Ave. Assessors <br /> WELL Location p Cross Street Thornton Rd. LODI 95245 055-320-24 <br /> City Zip Parcel# <br /> PROPERTY Richard Hokides <br /> Owner Address P.O. BOX 1411Clty P <br /> WOODBRIDGE ZI 95258 Phone#209-367-9330 <br /> Cascade Drilling3632 Omec Circle Rancho Cordova 95742 717510 <br /> C-57 Contractor Address City Zip Lic# Phone# 916-638-1169 <br /> Consultant/Sub Cnlr A.G.E. 837 Shaw Rd. Stockton <br /> p. A7ddpress City on Lic# Phone# 209-467-1006 <br /> GIS Coordinates:X �O. I' ,y�IZ.I. ,� { Townshi <br /> P Range Section <br /> WORK TO BE PERFORMED, <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") *DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> u WELL# T 0 &OVER-BORE. DIAMETER 12-INCH <br /> 0.Other GGGYYYrr g PRESSURE GROUT <br /> GROUT SPECIFICATIONSport land Type II <br /> COMMENTS: See Work Plan, dated 17 March 2008. Abandon wells EW-9 & EW-10 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS u MULTI-LEVEL WELL CASING DIA:_ <br /> g EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL u PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> ) <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 1 I 'D . C.,h Title/Company PROGECT GEOLOGIST/A.G.E. <br /> Print Name TIMOT19 JVCUELLAR <br /> Date 04/08/08 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted ByDate Issued �L/ �d <br /> Area D <br /> Grout Inspection By ate Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FE�EEIINNFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> aA SR 0.5 QA <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />