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�P• �(�!. C )San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> " (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> O• �P <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. <br /> 17, 310 N. Tull Road Brandt Lockeford 95237 Assessors 053-070-03 <br /> WELL Location y Cross Street City Zip Parcel# <br /> PROPERTY Frank Boleo, <br /> Owner Black Mountain Development Address 3925 Santa Rita Rd,#200 City Pleasanton Zip 94558 Phone#(925)520-0001 <br /> C-57 Contractor V&W Drilling Address 100 Fifth Street City Isleton Zip 95641 Lic#720904 Phone# (916)777-4100 <br /> Consultant/Sub Cntr ENGEO,Inc. Address 631 Commerce Drive,#100 City Roseville Lic# Phone# (916)786-8883 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ONEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) aDESTRUCTION (choose type below) <br /> ❑SOIL BORING# ❑OVER-BORE. DIAMETER <br /> DWELL# 1 (MW-5) []PRESSURE GROUT <br /> ❑'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING []HOLLOW STEM DIA.OF BOREHOLE loin. []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: 4 in. <br /> ❑EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS SCh 30 TYPE OF CASING: []STEEL E]PVC []OTHER: <br /> ❑VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 117 ft TREMIE TYPE TO BE USED: ❑]AUGERS []HOSE <br /> ❑AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ❑✓Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING []HAND AUGER GROUT SPECIFICATIONS Neat cement with tremie pipe <br /> []OTHER: I1 OTHER APPROX.BORING DEPTH 150 feet a BOLTED TRAFFIC BOX or O 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 Ord' rg¢, R��IPa and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company ENGEO, Staff Engineer <br /> Print Name Jo urato Date 9/23/05 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: /� S vv — S_� V' � 0 F0! <br /> Application Accepted By F' � _ Date Issued i0� 2 / Area �/ r <br /> Grout Inspection By _ 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/SERVICE REQUEST# INVOICE <br /> 5'1q�l 44 '7/27 l SR#00yL/()&'7 <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 />