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'Pq"'"'`' 'S"Xn Joaquin County <br /> -�- Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ,* <br /> (209) 465-3449 Fax: (209) 463-3433 Web: w«vw.sjgov.org/ehd <br /> UNIT !V <br /> ,.4, <br /> Well Permit Application <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 936 City Zamora Zip-95207 Lic#283326 Phone# 530-662-2829 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y Township 2 North Range 6 East Section 19 <br /> WORK TO BE PERFORMED: <br /> [xl NEW WELL /BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) [i DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> [Xl WELL#_ MW-10 [l PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X MONITORING X HOLLOW STEM DIA.OF BOREHOLE 8" n MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: 2" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0,020 TYPE OF CASING: 0 STEEL X PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_0-4 feet TREMIE TYPE TO BE USED: [X]AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:, OiYes 0 No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 20' X BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—NO (if YES,list specifications in comment section) <br /> COMMENTS: Sau1'l. Q1 <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 �' Title/Company_P1n}Prt_.ranlannict-SF-CQR International Incorporated <br /> Print Name Michael Sperber Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: ���21(� q <br /> Application Accepted By Date Issued .S �Q Area / <br /> Grout Inspection By Date f Final Inspection By <br /> L_U-.,'Q r-'( Q,- Date [ 1 (? <br /> i <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: " <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK It REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 71 -7SR# 25 6g3 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> LFID 24-02-001 <br /> 6/22/04 <br />