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t • <br /> FILE COPY <br /> *an Joaquin County <br /> v � Environmental Health Department SITE <br /> ¢' 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> n 2008 (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> NTHEAM Well Permit Application <br /> PERMIT;SEIRVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C) <br /> Application is hereby made to San Joaquin County for a permit to construct and/dr 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 /> Capitol Ave. LODI 95245 Assessors 055-320-24 <br /> Th <br /> WELL Location 6421 Capitol Ave. , Lodi CA Cross Street ornton Rd. City Zip Parcel# <br /> PROPERTY Richard Bokides P,0. BOX 1411 WOODBRIDGE 95258 209-367-9330 <br /> Owner Address City Zip Phone# <br /> Mitchell Drilling 7900 Myrtle Ave. Eureka Phone# <br /> 95503 672617 707-444-9040 <br /> C-67 Contractor Address City Zip LIc# <br /> A.G.E. Address 837 Shaw Rd. City,Stockton Uo# 680227 phone# 209-467-1006 <br /> Consultant/Sub Cntr '7,((jj <br /> GIS Coordinates:X ✓r+• —A—,y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CEI.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) VSER RU <br /> RE. D(chopse s/lo/type ETER_ ielow) <br /> a SOIL BORING# a PRESSURE GROUT <br /> aWELL# GROUT SPECIFICATIONSportland Type II <br /> p•Other, <br /> . Abandon wells MW-1/2/4/5/8/9 & EW-1 through EW-10 <br /> COMMENTS: See Work Plan, dated 17 March 2008 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING u HOLLOW STEM DIA.OP BOREHOLE_ a MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL B PVC B OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS u HOSE <br /> p AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_G 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 /> Title/Company PROGECT GEOLOGIST/A.G.E. <br /> 9 <br /> Si nedx L � 04/08/08 <br /> Print Name TIMOTHY J. CUELLAR Date <br /> DEPARTMENT US/E' ONL,Y�/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: tlo9( / GIS cgjoti1 a� <br /> WORK PLAN DATED: oil <br /> Application Accepted By <br /> Date Issued �" !d Areay� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> oil- W 60- 273 � SR 00 G 5 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />