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FAC# ACCOUNTING ONLY: I AID# <br />COMMENTS CONDITIONS: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br />'Final Inspection By ‘XcL/Q-,,, <br />Date <br />Date <br />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/elid <br />Well Permit Application <br /> <br /> <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 Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 6717 Plymouth Road Cross Street West Benjamin Holt Drive City Stockton Zip 95207 Parcel#_097-600-02 <br />PROPERTY <br />Owner Motel 6 Operating L.P. Address 14651 Dallas Parkway Suite 500 City Dallas Zip 75240 Phone# 972-702-5995 <br />C-57 Contractor WDC Exploration and Wells Address 9580 County Road 93B City Zamora_7jp_95207 Lic# 283326 Phone# 530-662-2829 <br />Consultant / Sub Cntr <br />GIS Coordinates: X <br />Address City <br />, Y Township 2 North Range 6 East Section 19 <br />Lic,# Phone# <br />WORK TO BE PERFORMED: <br />[X] NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHERS) [] DESTRUCTION (choose type below) <br />0 SOIL BORING # a OVER-BORE. DIAMETER <br />[X] WELL #_ MW-10 0 PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS:. <br />ZONE <br />TYPE OF WELL <br />X MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />13 AIR SPARGE/ 0 <br />a SOIL BORING <br />0 OTHER <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />X HOLLOW STEM DIA. OF BOREHOLE 8" 11 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: __2" <br />O AIR HAMMER/DRIVEN CASING THICKNESS 0,020 TYPE OF CASING: a STEEL X PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL_0-4 feet TREM1E TYPE TO BE USED: [X] AUGERS 13 HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED:, 13,Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER APPROX. BORING DEPTH 20 X BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <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 /> Title/Company_PrnkInt nenIngist SECOR International Incorporated <br />Date 1)- C —0 —) <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ..2 416.,5 <br />WORK PLAN PLAN DATED: EP-2)6 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE -".-----1--k9E 141ff-il-,SERILLGEREOUESI OICE <br />350 1 .g1 li Cl 71z-7 1 --frv_ Q57 67 sR# 5-683 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />Print Name Michael Sperber <br />EHD 29-02-001 <br />602/04