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SITE <br />MITIGATION <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Application Accepted Accepted By <br />Grout Inspection By , <br />Destruction Inspection By s--6.,W47,777A, <br />WORK PLAN DATED: 5 /Pa 01 <br />Date <br />C. 6 7 Area 6-/Ici <br />--12, -07 <br /> <br />Date Issued Issued <br />Date Final Inspection By <br />Date <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor,rStockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES i 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 />Assessors WELL Location 6619 Plymouth Road Cross Street West Benjamin Holt Drive City Stockton_Zip 95207 Parcel# D9.7-630-07_ <br />PROPERTY <br />Owner Ronald G. Fry Address 6619 Plymouth Road City Stockton Zip 95207 Phone# unknown <br /> <br />C-57 Contractor WDC Exploration and Wells Address 9580 County Road 93B <br /> <br />City Zamora _Zia 95698 Lic# 283326 Phone* 530-662-2829 <br /> <br />City Lic# Phone# <br />GIS Coordinates: X -121.3500952 Y 38.0040490 Township 2 North <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') [x] DESTRUCTION (choose type below) 0 SOIL BORING # [X] OVER-BORE. DIAMETER [)WELL # PRESSURE GROUT <br />[X] 'Other Destroy Well MW-4 GROUT SPECIFICATIONS <br />COMMENTS: ARCOs MW-4 was paved over. The drilling company will locate and destroy the old well (MW-4). <br />• <br />TYPE OF WELL <br />X MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />D OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />X HOLLOW STEM DIA. OF BOREHOLE 10" [] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2" <br />0 AIR HAMMER/DRIVEN CASING THICKNESS 0,020 TYPE OF CASING: 13 STEEL X PVC 0 OTHER: <br />13 MUD ROTARY DEPTH OF GROUT SEAL 0-9 feet TREMIE TYPE TO BE USED. [X] AUGERS I] HOSE <br />PUSH POINT (GP or CPT)GROUT SEAL PUMPED: °Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS <br /> <br />El OTHER APPROX. BORING DEPTH 30' X BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (If YES, list specifications in comment section) <br />COMMENTS: <br /> <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name jvlichael Sperber <br /> <br />Date <br /> <br />DEPARTMENT USE ONLY <br /> <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />---.....,...._). <br />SR °0549g SI <br />PE CODES FEE INFO AMOUNT REMITTED CHECK t-' REC'D BY DATE PERMI ; • • INVOICE <br />3c0 9` 12 0 lq 0 i )551 Cl -72/%--- 4/670 -) sR# Fo ,K3 7 <br />Consultant / Sub Cntr Address <br />Range 6 East Section 19 <br />Title/Company_Prn?rt Spologist SFCOR International Incorporated <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EI-113 29-02-001 <br />6/22/04