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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 />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This api:qcattqn js.made in.doinOir6g4th San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Delving*o T AL <br />if LT iiPaieRsibrg T TIENT City Lanthrop Lip Parcel# <br />PROPERTY <br />Owner James M. Langston Address PO Box 97 <br />C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave <br />Consultant/Sub Cntr Adv GeoEnvironmental. -pAddress 837 Shaw Road City Stoctkon Lid* phone# 467-1006 <br /> <br />GIS Coordinates: X _ ,Y , Township Range Section <br />WORK TO BE PERFORMED: <br />[f NEW WELL / BORING (OPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />0 SOIL BORING #c, .. D OVER-BORE. DIAMETER <br />ffWELL # MW -9 --9fir • Obv 13 PRESSURE GROUT <br />a *Other DPE -1 GROUT SPECIFICATIONS <br />COMMENTS: <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />2001 JAN -9 PM 3: 06 <br />WELL Location 15615 South 7th Street Cross Street L Street <br />City Lanthrop 95330 Zip Phone# <br />city Eureka Zip 95503Lic#672617phone# 707-444-9040 <br />TYPE OF WELL <br />Ey MONITORING <br />EXTRACTION <br />VAPOR <br />a AIR SPARGE/ OZONE <br />a SOIL BORING <br />If-OTHER: DPE-3- <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />8 25 2-inch <br />If HOLLOW STEM DIA. OF BOREHOLE ' 1:1 MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA: <br />fl AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: a STEEL lyPVC 0 OTHER: <br />U MUD ROTARY DEPTH OF GROUT SEAL 10/10 TREMIE TYPE TO BE USED: if AUGERS D HOSE <br />a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a HAND AUGER GROUT SPECIFICATIONS Portland Cement <br />a OTHER APPROX. BORING DEPTH 25/25 tyBOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br />COMMENTS: 1 Monitoring Well to 25 feet, 1 DPE to 25 feet <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 Ordinans, Fil and $egulations, and all applicable California State Laws. <br />Signed x <br />Title/Company Vice President <br />Print Name Robert Marty Date 1-04-06 <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS'. <br />WORK PLAN DATED: -71:0 <br /> <br />DEPRTMENT USE ONLY <br />/q,(5 7 <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br /> <br />Date Issued Area <br />a Date Final Inspection B !TED ate /0,-/U-'.07ZAP <br />Date WO! <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE IVO AMOUNT REMITTED CHECK # REC'D BY DATE - - -, - -a ST INVOICE <br />OS 1'91* 37 4.-- xo.,--7 64 f--iy SR# <br />4 <br />F/WC ("WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />C-57 Letter of Authorization to sign permit E