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�9F N. SAN JOAQUIN COUNTY <br /> A1 ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:V8M.sictev.or­qehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, Assessorss <br /> Well Location 521 N Cherokee Cross Street Murray City Lodi Zip 95240 parcel#421-274-56 <br /> PropertyJose Garcia Address 3023 Woodson Rd cityAcampo Zip 95220 phone# (209)333-0187 <br /> Owner --- <br /> C-67Contractor V&W Drilling Address 3805 Duck Creek Drive City Stockton Zip CA Lic# 720904 phone <br /> 469-7700 <br /> ConsultanNSub Cntr Address_ _--__... City Lic# Phone <br /> GIS Coordinates X .Y Township 3N Range 6E Section 1 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> 9'OTHER2 oual Ne-ted raiaxce- 2e11 HaS, x esc:a:ceor, >e;>> GROUT SPECIFICATIONS <br /> 0 EXPLOSIVES DETONATING CARD <br /> COMMENTS Please see attached maps/documents from approved workplan <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> El MONITORING [*HOLLOW STEM DIA.OF BOREHO'_E -0 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: `+ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS:' TYPE OF CASING.0 STEEL. DO>VC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY -_—DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED'�lAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED.0 Yes V No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS SrfC.y., ,._",.- G'�.S F�1-'i� Y" N!l t? � <br /> 0 OTHER _ D OTHER APPROX.BORING DEPTH 25 ' -14 BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> CONDUCTORCASINGPROPOSFD (ii YES.list sl>solictticns in commintmUon) <br /> —__ <br /> COMMENTS '-:;: '. --. n!11 xe 2, ..cre.v;,0 <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 I accordance with San Joaquin County Ordinances, Rules antl <br /> Regulations,and all applicable California Laws. / <br /> Signed fi vr" / T -< Tine/Company Consultant/Geologist <br /> Print Name Steve Muir Date 5/3/2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.ADDRESS: AA <br /> "► <br /> WORK PLAN DATED. � &'V-QLA I )Lot <br /> APPLICATION ACCEPTED Y� 'E� .( DATE ISSUED I AREA <br /> GROUT INSPECTION Bldll--prt-D-Ci( FINAL INSPECTION BY DATE / lb <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PIT <br /> ERMlSERVICE# INVOICE <br /> 55--0/ 47 ' 254 ----_ P;: OZ 37 ' /d-C- 5 y /0 1 SR#EYlSTl87 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10r28/09 <br /> WELL PERMIT APP <br />