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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <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 />SITE <br />MITIGATION <br />UNIT IV <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 Tit e, Chapter 9-1115. ante Standards of San JoaquinCounty Environmental Health Department. <br />ronq ( Iv Assessor's <br />WELL Location �Aue-- ross Street Austin Road City Ripon Zip 95366 Parcel# 243-24-041 <br />oc.tai ,(SZDj &ie^ � J a <br />PROPERTY Owner iEicc _ ,"� Address City Zip—�� Phone# 20 <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 />PE CODES <br />Consultant/ Sub Contractor_ Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br />AMOUNT REMITTED <br />GIS Coordinates: X 121.1646779°W Y 37.7642205°N Township 2S Range 7E Section 14 <br />REC'D BY <br />WORK TO BE PERFORMED: <br />-� <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") [X] DESTRUCTION (choose type below) <br />C) <br />0 SOIL BORING # 0 OVER -BORE <br />33 3 <br />0 WELL # [X] PRESSURE GROUT <br />�- <br />'Other: Grout Specifications: Neat cement grouttremied then pressure r <br />COMMENTS: Destroy wells off-site wells MW10, MW12, MW14, MW18 - jr, S-(-LI(c� I ueS (q�Tr <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r�O <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0., VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE SED: 0 AUGERS 0 HOSE <br />+, <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 fl BOLTED TRAFFIC BOX or 0 STOVE PIPE` <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />'COMMEN <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 Ord�inrceQ Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company CA Registered Geologist 6795 Gr and Zero Analysis, Inc. <br />Print Name John P. Lane Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: LO d <br />Application Accepted By Date Issued /��Q Area / �Z <br />Grout Inspection By 1/11Date SL// Final Inspection By Date <br />Destruction Inspection By 'ZrL� Date ( /S LY <br />r`r1MM9=AITC /r.r)Kjn1TI0NC-v-,c r6ac 0(IY�v� C.T � �L( <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P EST # <br />INVOICE <br />33 3 <br />�- <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 1/2b/02 <br />