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Flan Joaquin County <br />Envirurimental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95 ITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/e d UNIT IV <br />t0� Well Permit Application 2 2 1006 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE Is9bWONMIENT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ cEFTNQ F&fjtls ade in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Depa m nt. <br />Assessors <br />WELL Location 444 Mossdale Road _Cross Street Interstate 5City Lathrop Zip9Jr33 C' Parcel# 23'703603 <br />8 X4-7 <br />PROPERTY <br />Owner Mel Bokides Petroleum Address P. 0. Box 7747 City Stockton Zip 95267 Phone#209-952-0868 <br />C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave City Eureka Zip 95503 Lir# 672617Phone# 707-444-9040 <br />Consultant/ Sub Cntr Adv GeoEnvironmenta�Address 837 Shaw Road City Stoctkon Lic#4,12 6,/?Phone# 467-1006 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />00 WELL # MW- 6, MW- 7, EW- 1 ORIGINAL <br />G RPRESSURE OUT SPEC F COAUT <br />T ONS*Other <br />COMMENTS: -- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2 -inch <br />[MONITORING HOLLOW STEM DIA. OF BOREHOLE e.zs/12 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 4=inch <br />EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL [r -PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2 - 35 TREMIE TYPE TO BE USED: If AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED:. -Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement <br />21-4- 35 oior: <br />0 OTHER:_0 OTHER APPROX. BORING DEP I V <br />v th 1-!r -0'7 <br />CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br />COMMENTS: Two monitoring wells and one extraction well. Extraction well is 4 -inch diameter (see work plan) <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 Ordinan IA�d egulations, and all applicable California State Laws. <br />�� M�' Vice President <br />Signed x Title/Company <br />Print Name Robert Marty Date 11-22-06 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted, /By Date Issued 1- .5-02 Area 14 S <br />Grout Inspection By md(_44r-i4g,,4 Date -0 Final Inspection By Vj cibc;,& �.Ii1cL�dY�i2 to 1- /8 -Orf <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: <br />,( r'nl iNITINr, nN1 Y AID# FA ('# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P T # INVOICE <br />35o I <br />28 S <br />374 <br />SR# 04- 8 <br />C-57_ WC= WAIVER C-57 Letter of Authorization to sign permit_ Encroach-imenf doc <br />EHD 29-02-001 <br />6/22/04 <br />