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WELAPERMIT APPLICATION FuRM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <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 Joaquin County Environmental Health Department. <br /> Assessor's <br /> WELL Location 11651 Palm Lane CrossstreetAustin RdcityManteca Zip 1535 Parcel# 070--G <br /> PROPERTYOwnerPaul & Kay GirdnerAddress P.O. Box 795 ciodesto zip 95353DnoneQ09 577-5721 <br /> C-57 Contractor V&W Drilling Address100 5th Street CityIsletonzip Lic#720904one#g1 r,7:7:7-410( <br /> Consultant/Sub ContractorGround Zero Address1714 Main St. CityESca1OnLic# Phonet209 838-9888 <br /> GIS Coordinates:X 121 . 164677YW _37.7642205ToNnship 95 Range 7E Section 14 <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') $DESTRUCTION(choose type below) <br /> 0 SOIL BORING# MW 19 0 OVER-BORE <br /> ItWELL#MW 14R I[PRESSUREGROUT <br /> 'Other: Grout Specifications: Neat Cement 23-5% bentonite <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X[kMONITORING XTHOLLOW STEM DIA.OF BOREHOLE 8" MULTIPLE CASINGS?0 YESXD[NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSch 40 TYPE OF CASING: 0 STEEL PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5 . 5f t. TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: )p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS:Neat Cement/bentonite <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 2 7" M BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?no (if YES,list specifications here): <br /> 'COMMENTS: (it" s0 5 <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 Ordin nce Rules and Regulations, and all applicable California State Laws. <br /> Signed Title/Company Registered Geologist 6795 Ground <br /> Print Name John Lane Date 3/27/03 Zero <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ( (^5 I F� �/� �� <br /> WORK PLAN DATED: 3 ;k, U <br /> Application Accepted By Lt_"rf Date Issued f5 Area <br /> Grout Inspection By Date Final Inspection B Date <br /> Destruction Inspection By Date b - <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FArit <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> aR001 14 V)100 12-1-07 G -f/;,;,/0 13 '3 3 3 :�L <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />