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: �- <br />R <br />pan Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />AID# <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 />10842 S. Harlan Road Assessors <br />WELL Location Cross Street Roth Road cityFrench Camp Zip 95231 Parcel# 1933028 <br />PE CODES <br />PROPERTY <br />AMOUNT REMITTED <br />Owner Beneto, Inc. Address 4080 Seaport Blvd City W. Sacto Zip 95691 Phonee#5 (916) 677-0817 <br />REC'D BY <br />DATE <br />C-57 Contractor V&W Drilling Inc Address P.O. Box 970 City Lodi Zip 95241LiC# 720904Phone# (209) 369-9600 <br />Consuftant/Sub Cntr Lee & Pierce, Inc. Address 3800 McHenry Ste.ICity Modesto Lic# PG 6795 Phone# (209) 527-1247 <br />� <br />GIS Coordinates: X 37.513065912 y-121.164281378 Township Range Section <br />(>0"" <br />WORK TO BE PERFORMED: <br />5 <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") gDESTRUCTION (choose type below) <br />OCA <br />D SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # VPRESSURE GROUT <br />N <br />0 "Other GROUT SPECIFICATIONS Neat Cement <br />COMMENTS: Pressure grout wells MW -1, MW -2, MW -3, overexcavate to 3 feet with 24 -inch auger <br />(� <br />V <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />J <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS D HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)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: D OTHER APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Ordinances. Rules and Regulations, and all applicable California State Laws. <br />Signed — Title/Company Professional Geologist 6795 <br />Print Name John P. Lane Date 07/23/07 <br />SITE MAP IN UNIT IV F <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />IdRSFZ S. 14&A,(,-JQcl - Lop wc�✓ 'h1� 3S oz <br />Application Accepted ByDate Issued 7/ 3002 Area '7? 7 <br />_ i0Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection BV Date cif o d <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />�. <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUE <br />INVOICE <br />� <br />J <br />(>0"" <br />f 7/ <br />21 <br />SR#�70�1 5�' <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ n <br />EHD 29-02-001 web <br />6/3/5.03 ° d-ev Ya <br />