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San Joaquin County <br /> Environmental Health Department NOVSITE <br /> r, 600 East Main Street, Stockton,CA 95202-3029 4 2001 MITIGATION <br /> • (209)468-3449 Fax::(209)468-3433 Web:www.sjgoNE*Yffl@NMENT HEALTH UNIT IV <br /> Well Permit Application PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <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 M 125;3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 7 � W. � 1f, Cross Street Ci Assessors <br /> C�SO r► tY c. �r� Zip 95:�0 L Parcel* /G <br /> PROPERTY <br /> Owner�I � �j tS 1.1 Z Address 9 S 2 pt►Y C, . City 2�Zi 13 Phone# `_ 1Q 3 d 3 <br /> C-67 Contractor S1>C- Addressjqk` 14 2►t �./Q. iG-ity ip_ AyLi $3 32' hone#j t 0 2 3 6 6 28 L <br /> ConsultantISubdnIr Cy-ft- <br /> GIS <br /> y-TCGIS Coordinates:X Y Township Range Section <br /> WORK TORE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> a SOIL BORING# . II OVER-BORE. DIAMETER <br /> tNELL#&W-x 2 y V' t1Csm1MW^1114­101 M vv- 14^77 Ii PRESSURE GROUT <br /> U Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> PAONITORING U HOLLOW STEM DIA.OF BOREHOLE101#'13 MULTIPLE CASINGS II MULTI-LEVEL WELL CASING DIA: 2- <br /> II EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS, LL 4 0 TYPE OF CASING: [I STEEL VC 0 OTHER: <br /> B VAPOR I7 MUD ROTARY DEPTH OF GROUT SEAL 10. 7 0 TREMIE TYPE TO BE USED: 7XXUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: fes t7 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS �' cyN&M A 1#1 i <br /> p OTHER:_ WOTHER '*jb%jX t_. APPROX.BORING DEPTH EU,,.�� OLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Of YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48WORKING 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 Title/Company Manager / WDC Exploration & Wells <br /> Prini Name Chris Tatum ---Date-11/7/07 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Li 20 W. 0-h a r-�e, Wa +✓ <br /> WORK PLAN DATED: N nV .rn ID ,T ZOD <br /> Application Accepted Date Issued 5 <br /> Jl-J 3-d 7 Areal 4 <br /> Grout Inspection By r Date 4-. 4(OR -Yinai inspection By Date .2 ' <br /> Destruction Inspection By Date r I <br /> COMMENTS I CONDITIONS: S - M V1-1 'SD _ _14,- W-/V-77 <br /> ACCOUNTING ONLY: AIDS <br /> FACS <br /> PE CODES FEE INFO AMOUNT REMITTEtS CHECK# REC'O BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3So ► <br /> 99,od 99. d-JsR# <br /> 020? to G Lel /1-13-07 <br /> C-57_ WC_ WAIVER G-57 Letter of Authorization to sign permit_„__,Encroachment doc <br /> EH.D29-02•ODt WEB <br /> 9/31/2007 <br />