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Ran Joaquin County RD Ecr,"YED <br />Environmental Health DepartmMP 0 4 2007 SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, �QVN ENT HEALTt l MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjg%ERVICE 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. <br />983 Moffat Blvd Cowell Ave. Manteca 95337 Assessors 22115006 <br />WELL Location Cross Street City Zip Parcel# <br />PRO PF2e1 Bokides Petroleum PO Box 7747 Stockton 95267 952-0868 <br />Owner Address City Zip Phone# <br />Cascade Drilling INC. 3632 Omec Circle Sacramento 95742 717510 916-638-1169 <br />C-57 Contractor Address City Zip Lic# Phone# <br />Consultant/ Sub Cntr Advanced GeoEnvironmentalAddress R;7 .9haw Rr3 City Stockton Llc# 680227 Phone# (209)467-1006 <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />0 *Other <br />Y <br />Township. <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) <br />Range, <br />Section <br />6DESTRUCTION (choose type below) <br />[kOVER-BORE. DIAMETER eight and twelve <br />0 PRESSURE GROUT inch drill outs <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[kMONITORING D: HOLLOW STEM DIA. OF BOREHOLE 8/12 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2/6 <br />[;EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 30 feet TREMIE TYPE TO BE USED: GAUGERS 0 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 Portland <br />0 OTHER: p OTHER APPROX. BORING DEPTH 30 feet BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section; <br />COMMENTS: destruction of monitoring wells and �X }rQ� fidY�LtIC�� �LcJ-� <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 0di ancesWa al Regulations, and all applicable California State Laws. <br />Signed x �," Title/Company Geologist / AGE <br />Print Name <br />William Little Date 31 August 2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: , <br />Application Accepted By V j CAm r; 4 L. /YI�AJ21 fG <br />Grout Inspection By a ))7"6?1 fw&-, Date <br />Destruction Inspection By V ; , � L r; U : {-,,1.C. Date <br />COMMENTS / CONDITIONS: <br />inch <br />Date Issued 9- /2 -61 Area <br />Final Inspection By V iC �D r cr Y1)� rh z,. Date Q Gfbbf/t'__ �Zd D'7 <br />re»Ube{ l9 x.70..2b01740C- �, ;100'7 <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P / SERVICE <br />INVOICE <br />. 50 3 <br />. ,t* <br />354. vo <br />u <br />-My <br />/� o � SR# 6 3 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ <br />oachment doc <br />EHD 29-02-001 <br />6/22/04 <br />