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WELL PERMIT APPLICATION FARM 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 Title, Chapter 9-1115.3 and the Standards of San JoaquirCounty Environmental Health Department. <br /> Assessor's <br /> WELL Location 11651 Palm Lane Cross Street Austin Road City Ripon Zip 95366 Parcel#" . <br /> 1'hA o[P�7 <br /> PROPERTY Owner M&L Commodities Address P.O. Box 795 City Zip 95353 Phone# 209-577-5721 <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 MainStreet 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 excavate 3 ft <br /> COMMENTS: Destroy wells MW3 MW6 MW7A MW713MW9_A9W MW11 f' -F [414 MW20 <br /> YYI;�'3�r�j i✓ ��I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?DYES ONO WELL CASINAIA:1 .%y� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICIWESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 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 �k,\ -fib 0 BOLTED TRAFFIC BOX or 0 STOVEPIPE <br /> CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> *COMMENTS: �y� (ry 7 / rA(dj 4 17 <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 /> 1 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 /> Signed x t �'l/� Title/Company CA Registered G�e10-lo ist 6795, Ground Zero Analysis, Inc. <br /> Print Name John P. Lane Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS-: d 1 <br /> WORK PLAN DATED: `! LUtJJ I / <br /> Application Accepted By - Date Issued1 /�/��j Area <br /> Grout Inspection By Date G / 0 Final Inspection By Date <br /> 0 r <br /> Destruction Inspection By`—�✓Z - Date CP ((! <br /> COMMENTS/CONDITIONS C A '] b <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a��a- Cod L�� t 3 3a3SR# <br /> ermit Encroachment doc 1/25/02 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign p <br />