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1�NED WELPPERMIT APPLICAT �ION FRM <br /> SITE <br /> JUN 1 5 2006 SAN JOAQUIN COUNTY MITIGATION <br /> HEA NVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber Stockton, CA'., 95202 <br /> PERIMF1i � ICES , Third Flooir, <br /> (209) 468-3449 <br /> " FILE COPY <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 JoaquirCounty',Environmental Health Department. <br /> h' Assessor' /r 2� <br /> WELL Location 5151 Almondwood Drive Cross Street Oleander City Manteca Zip 95337 Parcel#,2 ` Z 3 <br /> PROPERTY Owner William Harris Address5151 Almondwood Drive City Manteca Zip 95337 Phone# 209-239-1361 <br /> l ii <br /> C-57 ContractorV&W Drilling, lnc „_,_Address100 Fifth Street P.O.Box 416 City Isleton Zip 95641 Lic# 720904 Phone# 916-777-4100 <br /> Consultant!Sub Contractor Ground Zero Analysis Inc Address 1714 Main Street City Escalon Lio# Phone# 209-838-9888 <br /> GIS Coordinates:X Y ,township '2S Range 7E Section 19F <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) [X]DESTRUCTION (choose type below) <br /> [I SOIL BORING# <br /> []WELL# [X]OVER-BORE(MW1-MW1 o) <br /> [X]PRESSURE GROUT(MW11) <br /> 'Other. Grout Specifications: Neat Cement <br /> COMMENTS: Destroying existing wells MW1-MW10 by overdrilling and grouting, destroying well MW11 by pressure grout/overdrill 5ft. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' <br /> MONITORING 0.HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> Q EXTRACTION .0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL [I PVC OOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE::MAXIMUM FREE-FALL DEPTH IS 30') <br /> i <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDP '' (if YES, list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> 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 <br /> County Ordi anc `"�,, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company CA Re istered Geologst6795 Gr and Zero Analysis, Inc. <br /> Print Name John P. Lane ! pate i 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5[S ! <br /> WORK PLAN DATED: d <br /> Application Accepted By Date Issued �--/ 'U p _ Area ! �� <br /> Grout Inspection By Date Final Inspection By Date <br />! Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS I; <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE '' PERMIT/SERVICE REQUEST# INVOICE <br /> 33 '� LAI 13 1 <br /> C-57— WCC WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />