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SITE MAP IN UNIT IV FILE, ADDRE,S <br />WORK PLAN DATED: \.; LA) <br />Application Accepted By <-711 - <br />Grout Inspection By - <br />Destruction Inspection By .-----17"/ <br />14.4,6,(4.--) 5 — ct 0 <br /> <br />Area <br />7 1 <0 /10 Final Inspection By Date <br />O Li/ Date Issued <br />Date <br />Date <br />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 />SITE <br />MITIGATION <br />UNIT IV <br /> <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 JoaquirCounty Environmental Health Department. <br />Assessor's „221-09'0-0:25 WELL Location 11651 Palm Lane Cross Street Austin Road City Ripon Zip 95366 Pa rce I# 2l 0-1-t.. <br />de..204-0 <br />PROPERTY Owner M&L Commodities Address P.O. Box 795 City attitrrttres Zip 95353 Phone# 209-577-5721 <br />C-57 Contractor V&W Drilling Inc. Address P.O. Box 416 City Isleton Zip 95641 Lic# C57-720904 Phone# 916-777-4100 -e <br />Consultant/ Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br />GIS Coordinates: X 121.1646779°W Y 37.7642205°N Township 2S Range 7E Section 14 <br />WORK TO BE PERFORMED: <br />['NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") [X] DESTRUCTION (choose type below) <br />fl SOIL BORING # B OVER-BORE <br />0 WELL # <br /> [X] PRESSURE GROUT <br />*Other: Grout Specifications: Neat cement grout tremied, then pressure, excavate 3 ft <br />COMMENTS: Destroy wells MW3, MW6, MVV7A, MVV7B, MVV9,111111101 MVV11, to=2„ MW20 <br />&" <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i Y10.34i-ri O Lt II <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING 6IA: -',// a-thtte, <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ['STEEL ['PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ['HOSE <br />I] AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: El Yes El 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 3-)L.) 41) :)\(..) ll BOLTED TRAFFIC BOX or ['STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />)0 f c '7 *COMMENTS: 7 1 ‘7 ( , ) r ,: ',--, 76/ . i / ,_. 76 / i 1 6 ,1 / <br />( 1 <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />k_ <br />Print Name John P. Lane <br />DEPARTMENT USE ONLY <br />COMMENTS / CONDITIONS Iv *\ 11,\? . cj <br />Signed x Title/Company CA Registered Geologist 6795, Ground Zero Analysis, Inc. <br />Date 0- (I <br />ACCOUNTING ONLY: <br />„ , <br />AID# FAc# <br />,- ----, <br />57 po tn <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE MTT7RVtEREQUE INVOICE <br />Leo 13 363 sR# 3 .33- ---c)------ <br />C-57 <br /> <br />WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />1/25/02 <br />