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RECSIED WELL PERMIT APPLICATION FORM <br />5 2.Qti6 <br /> <br /> SAN JOAQUIN COUNTY <br />HE otfNVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 PERM /SERVICES <br />SITE <br />MITIGATION <br />UNIT IV <br />(209) 468-3449 ORIGINAL <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 JoaquinCounty Environmental Health Department. <br />Assessor' <br />WELL Location 5151 Almondwood Drive Cross Street Oleander City Manteca Zip 95337 Parcel#.2'13 1 3O - 1 3 <br />PROPERTY Owner William Harris Address 5151 Almondwood Drive City Manteca Zip 95337 Phone# 209-239-1361 <br />C-57 Contractor V&W Drilling, Inc. Address100 Fifth Street, P.O. Box 416 City Isleton Zip 95641 Lic# 720904 Phone# 916-777-4100 <br />Consultant/ Sub Contractor Ground Zero Analysis, Inc. Address 1714 Main Street City Escalon Lic# Phone# 209-838-9888 <br /> <br />GIS Coordinates: X <br /> <br />, Y Township 2S Range 7E Section 19F <br /> <br />WORK TO BE PERFORMED: <br />[ ] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />[ ] SOIL BORING # <br />[ ] WELL # <br />*Other: Grout Specifications: Neat Cement <br />COMMENTS: Destroying existing wells MW1-MW10 by overdrilling and grouting, destroying well MW11 by pressure grout/overdrill Sit. <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? [I YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL [ ] PVC 00THER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: B Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH ['BOLTED TRAFFIC BOX or ['STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <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 Ordiranc , Rules and Regulations, and all applicable California State Laws. <br />[X] DESTRUCTION (choose type below) <br />[X] OVER-BORE (MW1-MW10) <br />[X] PRESSURE GROUT (MW11) <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING U HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR UMUDROTARY <br />B AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING fl HAND AUGER <br />0 OTHER U OTHER <br />Title/Company CA Registered Geoloqst 6795, G( und Zero Analysis, Inc. <br />OCe (t(-1 Occ) <br />Signed x <br />Print Name John P. Lane <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: te (1/6 <br />Date <br />DEPARTMENT USE ONLY <br />Application Accepted By <br /> <br />(--7Y1 <br />Grout Inspection By Date <br />Destruction Inspection By tr.A.,--dati:a.,111teZeptylyy. Date <br />COMMENTS / CONDITIONS <br />Date Issued <br />Final Inspection By <br />,1?_1 7 o <br />(0)-1,7/6 <br />Area <br />Date <br />ACCOUNTING ONLY AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />Y€013 " )--19 4 3 3 CI 1 (P 1 '.Z, SR# <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />t doc <br /> <br />1/25/02 <br />