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WELL PERMIT APPLICATION F01M SITE <br /> OCT 5 2006 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENNRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMITISEMAGES (209) 468-3449 <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.Assessors <br /> WELL Location_3931 Newtown Road Cross Street_Wilson Way_City_Slockton_Zip Parcel# <br /> PROPERTY Owner—Ken Gillies Address_P.O.Box 8303_City_Stockton_Zip_95208 Phone#_209 948 6268_ <br /> C-57 Contractor_V&W Drilling_Address_P.O.Box 51_City_Rio Vista_Zip_94571_Lic#_C57-720904_Phone#_916 777 4100_ <br /> Consultant/Sub Cntr_Upgradient Envionmental C._Address_3369 Kimberly Rd_City_Cameron Park_ Lic#_RG 4717_Phone#_530 677 3055_ <br /> GIS Coordinates:X <br /> y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> pq NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> [X]SOIL BORING#_2 D OVER-BORE. DIAMETER <br /> WELL# 5 D PRESSURE GROUT <br /> [X] <br /> [X]WEOtherGROUT SPECIFICATIONS <br /> 11 COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X]MONITORING [X]HOLLOW STEM DIA.OF BOREHOLE_8.51,D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_2 <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL IX]PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [X]SOIL BORING D HAND AUGER GROUT SPECIFICATIONS_Neat cement <br /> D OTHER: n OTHER APPROX,BORING DEPTH_70 [X]BOLTED TRAFFIC BOX or D 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 /> Tdle/Company c,`�� Jac%✓. 6.....- <br /> Signed x 4 << <br /> Print Name c %'/c ' Date ,L%� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: M/arch 27, 2006 as part of 1st Quarter Monitoring Report <br /> Application Accepted By ��G�7 Date Issued Z-? Area <br /> Grout Inspection By AefC�.Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> 22jjLTKE <br /> FAC# <br /> ITTED CHECK# REC'D BY DATE PERMIT ISERVICE REo 3(087 CUT_ /vos o(, SR# QO� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />