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WELL PERMIT APPLICATION FFvRM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (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 Tit e,Chapter 9-1115. and the Standards of San JoaquirCounty Environmental Health Department. <br /> )6Dn Assessor's <br /> WELL Location e-- Q ross Street Austin Road City Ripon Zip 95366 Parcel# 243-24-041 <br /> San o4 EA6 - a <br /> PROPERTY Owner Address City Zip S-14S& 2098 » <br /> C-57 Contractor V&W Drilling Inc. Address P.O. Box 416 City Isleton Zip 95641 Lic# C57-720904 Phone# 916-777-4100 <br /> Consultant/Sub Contractor Ground Zero Analysis Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br /> GIS Coordinates:X 121.1646779°W Y 37.7642205°N ,Township 2S Range 7E Section 14 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) [X]DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# [X]PRESSURE GROUT <br /> "Other: Grout Specifications: Neat cement grout tremied,then pressure rr <br /> COMMENTS: Destroy wells off-site wells MW10, MW12, MW14, MW18 — ��S lk� p�,4�n�(lK r ] t �S C �a�� I uf.54v:L0'- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL <br /> 'VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH () fl BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> "COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ord�injnceQ IR'ules and—Regulations, and all applicable California State Laws. <br /> Signed x Title/Company CA Registered Geologist 6795 Gr and Zero Analysis, Inc. <br /> Print Name John P. Lane Date 63 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: - �J <br /> WORK PLAN DATED: �J d <br /> Application Accepted By Date Issued 6 /I/Q Area / �2 <br /> Grout Inspection By 1iL` Date � S L' Final Inspection By Date <br /> Destruction Inspection By Ltic Date <br /> COMMENTS/CONDITION& � o gi S <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> r os 3334 2- <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 1/25/02 <br />