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J San Joaquin County • <br /> Environmental Health Department SITE <br /> "I N4 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> M1lnpp,,j.1(2Q9)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT IV <br /> Well Permit Application <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. 017-090-058, -50 <br /> Assessors <br /> WELL Locatlon5950 E. Woodbridge cross Street Kennef ick City Acampo Zip parcel# 018-010-22 <br /> PROPERTY <br /> Ownerobe,rt Mondavi AddressPO Box 1260 cibWoodbrid>;eZip 95258 Phone#209.369.5861 <br /> otraoant Sonic <br /> Contractor International Addres,220 N. East St. citWoodlandzip95776Lic#802334Phone#530.668.2424 <br /> San <br /> Consultant/Sub Cntyennedy/Jenks Address 622 Folsom St. CityFrancisd&# Phone#415.243.2150 <br /> GIS Coordinates:x-121.24458 y38.15802 Township 4N Range 7E section 31,32 <br /> WORK TO BE PERFORMED: <br /> Xfj NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) B DESTRUCTION (choose type below) <br /> 0 SOIL BORING SB-1 to SB-7 0 OVER-BORE. DIAMETER <br /> O WELL# MW– , MW-1U, MW-tt O PRESSURE GROUT <br /> O*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> II MONITORING II HOLLOW STEM DIA.OF BOREHOLE±7 in 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> O EXTRACTION O AIR HAMMER/DRIVEN I CASING THICKNESS 5C N 0 TYPE OF CASING: O STEEL XPVC O OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEALSee commentREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> O AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 4 Yes O No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> g SOIL BORING OHANDAUGER / GROUT SPECIFICATIONS Neat <br /> O OTHER:_0 OTHER APPROX.BORING DEPTH 80 f t VOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED No (if YES,list specifications in comment section) <br /> COMMENTS: 80' borings: 55' MW <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 Orantes, RuI s a Regulations, and all applicable California State Laws. <br /> Signed 4�CZ /,/`-sem( - Title/Company ` Ga(Or <br /> Print Name /"It G.N L N`fir^' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV Fil E,A DRESS: <br /> WORK PLAN DATED: 1T ZOOS' S7 <br /> Application Accepted/Bye // M.0- — Date Issued O b Area <br /> -997 <br /> /_ <br /> Grout Inspection By LIC n..6-f-e Data IJ G 0 Final Inspection By Date 0 <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/SERVICE REQUESTif INVOICE <br /> aR01 Bq " 8`t- 1s 23 /�� g a5 SIR o0 3 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />