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�OWED WELL FORRMIT APPLICATION FOFI SITE <br /> OCT 5 2006 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> FERMIT/SEMACES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pemtit 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. <br /> Assessors <br /> WELL Location_3931 Newtown Road Cross Street_Wilson Way_City_Stockton_Zip ParceMF <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_7ip_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 ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> [X]NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> [X]SOIL BORING#_2 a OVER-BORE. DIAMETER <br /> 1X1 WELL#__--_5— <br /> a PRESSURE GROUT <br /> p'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X]MONITORING [X]HOLLOW STEM DIA.OF BOREHOLE 8.5"a MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA:_2'_ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL [x]PVC 0 OTHER: <br /> p VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS o HOSE <br /> a AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [X]SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_Neat cement <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH_70 [X]BOLTED TRAFFIC BOX or a 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 Ordinanc/y uIe's/a' Regulations,and all applicable California State Laws. <br /> 9 <br /> Si nedx R/`i Title/Company ��5 ��•"�z J�✓Y =���,�+'1� <br /> Print Name C:c•r . ,� f�2'.•�'� �i <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / March 27, 2006 as part of 15 Quarter Monitoring Report <br /> Application Accepted By /✓G/7 Date Issued �Z3l0('. Area <br /> Grout Inspection By lL_ - _Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT ISE V ICE <br /> �375�.e0150 3 <br /> 3687 �NTpt /o es o� SR# pOy8779 <br /> C-57__ WC=WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />