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%ap�l^%- `�'an Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,iStockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> FILUM 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 6619 Plymouth Road Cross Street_West Benjamin Holt Drive City Stockton Zip 95207 Parcel#097-6,OD.L <br /> PROPERTY <br /> Owner Ronald G. Fry Address 6619 Plymouth Road City Stockton Zip 95207 Phone# unknown <br /> C-57 Contractor WDC Exploration and Wells Address 9580 County Road 93B City Zamora ip 95698 Lic#283326 Phone#_530 662-2829 <br /> Consultant/Sub Cntr Address City LickPhone# <br /> GIS Coordinates:X -_121.3500952 Y 38.0040490 Township 2 North Range 6 East Section 19 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) [x[DESTRUCTION (choose type below) <br /> 0 SOIL BORING# [XI OVER-BORE. DIAMETER <br /> [I WELL# _ []PRESSURE GROUT <br /> [X]"Other Destroy Well MW-4 GROUT SPECIFICATIONS <br /> COMMENTS:ARCOs MW-4 was paved over. The drilling company will locate and destroy the old well(MW-4). <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X MONITORING X HOLLOW STEM DIA.OF BOREHOLE 10" 0 MULTIPLE CASINGS 0 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-0-9 feet TREMIE TYPE TO BE USED: [XI AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 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 30, X BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—NO (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 /> Signed x Title/Company_P-mient Geoingict ISEQQR IR"L�ernational II/ ``nccom""oor�rated <br /> Print Name Michael Sperber Date ?�� `J T_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 3/o�a 0-] <br /> Application Accepted By Date Issued /r/ d Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date�aj/ � Date is .� Z _0 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3,r,d ?` Q 1?t'(o 0 -7),575-1`j o SR#5'0$3 7 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 17HD 29-02-001 <br /> 6/22/04 <br />