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San Joaquin County <br />Environmental Health Department <br />{ 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />` Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ISIF <br />I 7 <br />44TI ION <br />ENVIPONf MMNLTH <br />PERMIT4 <br />4Q-0' <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 />3780 West Linne Road Assessors <br />WELLLocatJon Cross Street HWY 5 CityTracv Zip95376 Pareelf 255-02-003 <br />PROPER Donald Sinclair 3780 West Linne Road Tracy 95376 (209) 833-7517 <br />Owner Address City Zip Phone$ <br />C-57 Contractor Soilprobe Address255 N Cherry St. 515CityTulare Zip93274Lk*870745Phonee (559)684-7200 <br />ConsultentlSub CntrGeological Technics Address 1101 7th Street Chy Modesto LiCS phot (209) 522-4119 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO_ BE PERFORMED: <br />D NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) j DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE- DIAMETER <br />0 WELL $ 0 PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS:Destruction of MW -1R, MW -4, MW -2, MW -3, MW -5, and MW -101 See attached Work Plan dated 07/09/07 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />FEE INFO AMOUNT REMITTED <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMEWDRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />D HAND AUGER <br />GROUT SPECIFICATIONS <br />0 OTHER: <br />It OTHER <br />APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: See Attached WP dated 07/09/07 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hepeby-certify at I have prepared this application and that the work will be done In accordance with San Joaquin <br />Couy O an , Rules and Regulations, and all applicable California State Laws. <br />Signedx Title/Company Soilprobe <br />Print Name Date '7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 7,SO C l h v. c V2U( i o, <br />WORK PLAN DATED: a- / 9 407 <br />r <br />Application Accepted By (1� r v� .,, Date Issued $ / g -/o ;Z Area � Lr <br />Grout Inspection By Date Final Inspection By Data <br />Destruction Inspection By (l'�r � 0-� Date -S/ Z3 e, <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: AID$ FACS <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK $ REC'D BY <br />DATE <br />0 <br />INVOICE <br />3 so 2 <br />s5--vo <br />460-00 <br />, mo o <br />�� 9 �-s 6 1�,� <br />g >� o� <br />/t <br />s <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ Ertcrodchment doc_ <br />EHD 29-02-001 <br />6/12/04 <br />