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uk114 ruU us:UJrn all wei fanaonment S3U.644.1939 • p,uZ <br /> SAN JOAQUIN COUNTY <br /> FILE COPY <br /> IVr0 ENVIRONMENTAL HLALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street,Stock ton, CA 95202-3029 MITIGATION <br /> u 4 `LTVaphone: (209)468-3454 Fax:(209)488-3433 Web:wWW.siaov.orG/ehd UNIT IV <br /> ENVIRON{'y'1ENTHEALTH WELL PERMIT APPLICATION <br /> PER k1lITIS ERV IvEsf1, ON-REFUNDABLE PERMIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or ins.aN the work described. This application is made in compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards or San Joaquin County Environmental Health Department. <br /> Well Location 14250 N.Devdes Rd. Cross Street W.Hamer Lane Assessor'- <br /> Property �h _Gtr Lodi Zip 95240 parcel#_ 0552-41)2, <br /> Owner— gJm-WeedsyU <br /> Address 14250 N.Devdes Rd. _City Lodi Zip 95240 Ptwne#(2091601-524U <br /> C•57 Contractor All Well Abandonment Address 6626Merchandise Way _ City Diamond Sodnos Zip 95619 Lic# 848359 Phone (800) <br /> 5060 Robert J Mathews Pkwy 948-1355 <br /> Consultant/Sub Cntr Dunn Env.,Inc Address Suite 2 _City EI Dorado Hills Lie# Phone (9161941-3650 <br /> GIS Coordinates:X_ Y ,Township -North—_ Range 6 East _Section 17,_1 B <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT.GEOPROBE HYDROPUNCH.HAND-AUGER,OTHER-) 13 DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> N WELL# Monitoring wells-MW-1 MW-2 MW-3 D PRESSURE GROUT _ <br /> ❑'OTHER GROUT SPECIFICATIONS 0. <br /> El EXPLOSIVES DETONATING CARD <br /> COMMENTS: \ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ry <br /> N MONITORING M HOLLOW STEM DIA.OF BOREHOLE IIrl_ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING'DIA�211ry1��,Q, `J <br /> 0EXTRACTION OAIRHAMMERIDRIVEN CASINGTHICKNESS 0,154 in. TYPE OF CASING:0STEEL DoPVCDOTHEB' "" \ <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL to>33 ft__TREMIE TYPE TO BE USED-O 4851is HO <br /> ❑AIR SPARGElOZONE 13PUSH POINT(GP OR CPT)_GROUT SEALPUMPEG: [KYss El No_(NOMAXIMUM F DEPTH IS 30') <br /> D SOIL BORING _ 0HAND AUGER GROUT SPECIFICATIC'NS ��V/ <br /> D OTHER: D OTHER: APPROX.BORING DEP rH 55 ft Der well D BOLTED TRAFFIC BOX OR ($STOVE PIPE <br /> CONDUCTOR GASINMi PR:)POSEu (r Es,lis,rynC111 jjms M[wn fs C4nn <br /> COMMENTS: 1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMEK; R ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the war ill be dor,e In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appll Ifor Is Laws <br /> Signed 1 �� TitlerComfany Nti \ 1 ,,s ntpaw mro 4 Y1es,,rf'`1 <br /> Print N <br /> Dato <br /> �\DEPA,R/TM T US ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY tl: AREA--i4-&'GROUT INSPECTION INSPECTION BY FINAL.INSPECTION BY OL DATE 674-10 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> WACCOUNTING ONLY: AID# FAc'# <br /> FEEINFO AMT REMITTED CHECK# RE CV'D BY DATE PERMITrSERVICE# INVOICE <br /> SR#WC -WAIVER C57 L ER OF AUTHORIZr'�TION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1028/09 <br /> WELL PERMITAPP <br />