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San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgiehd <br />Well Permit Application <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 />WELL Location 1 LI 4 LA c./i 1 t..) SI" . Cross StreetW• trf, 5:h,d(1))/t,kip <br />Assessor <br />Parcel* e CO3 06 5 — <br />PROPERTY <br />Owner 64.1.3/ket.9- OViviA- 0 1JAddress ?(..) e)t-41 -1 City 0Ailip qszz) Phone* (151-8401 <br />C-57 Contractor tjk./ c.) (7,- AddressAlt \ PAAQrs0- lestsk_ city Iti, -, zi rg4140111.1424417 phone#5- )0 236 212- <br />Consultant I Sub Cntr C. AddressWitiCt ell/ CM la Ct..bt. City fl1•40f)/tt Lk* Phonett 0 )1:1 55-- 9 850 <br />GIS Coordinates: X . Y Township Range Section <br />WORK TO BE PERFORMED: <br />--/PNEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') DESTRUCTION (choose type below) <br />1:1 SOIL BORING it (1 OVER-BORE DIAMETER <br />WELL* PRESSURE GROUT <br />*Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPWFICATIONS <br />)11.010NITORING °HOLLOW STEM DIA. OF BOREHOLE9 or id h MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA 2.* ' <br />fl EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS S.C.IN LIO TYPE OF CASING: (3 STEEL OVC fl OTHER: <br />O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f-ttt 1 TREMIE TYPE TO BE USED: ‘frAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP Of cPpoRou-r SEAL PUMPED: 8 Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />g SOIL BORING a HAND AUGER GROUT SPECIFICATIONS e0 f i-\04Y\ 611 /4.111\ <br />a OTHER: *OTHER f.0-1-0‘11,/“.., APPROX. BORING DEPTH S Dt /1430LTED TRAFFIC BOX or g STOVE PIPE <br />CONDUCTOR CASING PROPOSED 14 n (if YES, list specifications in comment section) <br />COMMENTS: <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 />WDC Exploration & Wells <br />Signed x Title/Company <br />Chris Tatum Print Name Date 9 / 6 / 0 7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 9Lic.) <br />WORK PLAN DATED: I2-1 L-7-1 0 6 a- ATAXAA.AA... bio1. <br />Application Accepted By ( Date Issued `*i tt 10r Area <br />Grout Inspection By Date I e) /241c Final Inspection By <br />Destruction Inspection By Date <br />Date cyf 5.7c, <br />COMMENTS I CONDMONS. <br />ACCOUNTING ONLY: AI C* FAD/ ,_';--R 006 r361 7 i <br />PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERI--MTSI E'RVICE-REQUESI it-- -INVOICE <br />SR# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001web <br />6/22/04 -00-)1-0.-) i--) In hi