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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 Joaquin <br />County Development Title, Chapter 9-1115.3 and the Standards of San JoaquIliounty Environmental Health Department. <br />Assessor's <br />WELL Location 7835 Thornton Road Cross Street Hammer Lane City Stockton Zip Parcel# 07749027 <br />PROPERTY Owner Knowles Family RevocableTrust Address: P.O. Box 640. City: Woodbridge zip: 95258 Phone# 209-367-6992 <br /> <br />C-57 Contractor V&W Drilling Address 100 5th Street City Isleton Zip 95641 Lic# 720904 Phone# 916-777-4100 <br />Consultant / Sub Contractor Ground Zero Analysis Address 1714 Main Street City Escalon Lic# Phone#209-838-9888 <br />GIS Coordinates: X ,Y ,Township 2N Range 6E Section 16 <br />WORK TO BE PERFORMED: <br />[X]NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br />a SOIL BORING # U OVER-BORE <br />[x] WELL # MW10 a PRESSURE GROUT <br />*Other Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[X] MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 12 'h" MULTIPLE CASINGS?[X] YES a NO WELL CASING DIA 65/8-2" <br />O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS_Sch40 TYPE OF CASING: [X] STEEL [X] PVC 0 OTHER: <br />0 VAPOR VW2 [X] MUD ROTARY DEPTH OF GROUT SEAL 86' TREMIE TYPE TO BE USED: a AUGERS [X] HOSE <br />AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: [x] Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Neat Cement Grout from surface to 86bqs <br />O OTHER: II OTHER APPROX. BORING DEPTH 100' [X] BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Yes ( if YES, list specifications here): <br />*COMMENTS: 6 5/8" diameter conductor casing will be installed to a depth of 80' <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. (12(‘)111, Cgz- 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 County <br />Ordinances Rule and Regulations, and all applicable California State Laws. <br />Signed x Title/Company RG. 6795, Groun Zero An lysis, Inc <br />Print Name John P. Lane Date 0 4 Ce <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application AcceptedBy <br />Grout InspectionBy <br />Destruction Inspection By <br />Dattssued 3( <br />Date 51/7/o& Final Inspection By Date <br />Date <br />Area qq) <br />COMMENTS / CONDITIONS tor 5/Y....t //go Lo. 41416..w.ht.fr4-... 1441-- <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE CE REQUEST # INVOICE <br />3c0 I E9 (1..1 F;t ri). /6067 4144— 5 /V <br />WC -WAIVER <br />.O 01-1q 2 7 <br />C-57 Letter of Authorization to sign permit Escachment doc <br />572.16 6 <br />C-57 1/25/02