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WELL *RMIT APPLICATION FOQVI SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> OCT 5 2006 <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENMRONMENT HEALTH 304 E. Weber, Third 9)or,31toc ton, CA., 95202 <br /> pERMIT�ERVICES <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 applicetion is made in compliance with San <br /> Assessors <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.arcet#__--- <br /> Cross Street_Wilson Way_._.CdY—Stockton <br /> WELL Location_3931 Newtown Road Stockton_Zip_95208 Phone#_209 948 6268_. <br /> _ <br /> PROPERTY OwnerKen Gillies�Address_P.0.Box 8303_CiIY_ <br /> C-57 Conlractor_V&W Drilling_Address_P.O.Box 51_City_Rio VS,, <br /> -720904_Phone#-916777 4100_ <br /> Consultant I Sub Cntr_Upgradient Envionmental C._Address_3369 Kimberly Rd_CityCameron Park_ Lick-RG 4717_Phone#_530 677 3055__ <br /> Township_ —.--- <br /> Range----Section <br /> GIS Coordin ales:X___— ,Y--�— <br /> WORK To BE PERFORMED: <br /> DESTRUCTION (choose type below) <br /> pt7 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') OVER-BORE. DIAMETER_-- <br /> pq SOIL BORING#__2_— --- <br /> Q PRESSURE GROUT <br /> # 5 GROUT SPECIFICATIONS__� <br /> pq WELL <br /> a*Other <br /> COMMENTS: <br /> TYPE�L� INSTALL CONST RUCTION SPECIFICATIONS <br /> pq MONITORING pq HOLLOW STEM DIA.OF BOREHOLE_8.5" MULTIPLE CASINGS 11 MULTI-LEVEL P CLL a OTIHER:IA:_2 <br /> TYPE OF CASING: U STEEL M HOSE <br /> a EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: 0 AUGERS <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEPL _ -- <br /> a AIR SPARGE!OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Il Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3 <br /> pq SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_Neat cement BOLTED TRAFFIC BOX or U STOVE PIPE <br /> n OTHER— APPROX.BORING DEPTH_70 iXl (if YES,list specifications in comment section) <br /> p OTHER: CONDUCTOR CASING PROPOSED� <br /> COMMENTS: <br /> NOTE: OFFSITE BORING <br /> 1oRKINc HOURS No CESS <br /> REQUIRED FOR INOSPECI7 oNOACHMENT PERMITS. <br /> 48 <br /> I hereby certify that I have prepared this application and/ca t the work will <br /> be one in accordance with San Joaquin <br /> s. <br /> County Ordinanc . yRules� Regulations,and all app y .s �� /�dk ✓ cS ���s 1 <br /> �� Tdle/company <br /> Signed), CCC Lc <br /> C. �, <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: March 27, 2006 as part of 1$ Quarter Mon 3�a 9 Repo Area.---- <br /> ,,/ / <br /> Date Issued Date_,_._---- <br /> Application Accepted By !V—G/7 Date Final Inspection By <br /> /i <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMISR#T� VI g ^ST# INVOICE <br /> �cr 3(087 �NTGZ /o of oL `� J <br /> mt� z �375 'e o 9/30/02 <br /> C-57_ iNC_ WAIVER__ C-57 Letter of Authorization to sign permit___.Encroachment doc� <br />