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FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton , CA . , 95202 <br /> (209) 468-3449 O N <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 /> Assessor's <br /> WELL Location 7499 EJ . Chart�eerr Way Cross Street Grant Street City Stockton Zip 95202 Parcel# 147-343-09 <br /> �/Z <br /> PROPERTYOwner/�/U �[//� WA ddress 0/1• #POAI City 57ZYXIMA/ Zip��?hone# <br /> C-57 Contractor Spectrum Exploration Address 2365 Wigwam Drive City Stockton Zip 95205 - Lic# 512268 Phone# 209-465-8712 <br /> Consultant[Sub Contractor Lee & Pierce. Inc. Address 546 Abbott Street, Suite 20 City Salinas Lic# Phone# 831 -758-0996 <br /> GIS Coordinates: X - 121 ,2776538 Y 37 .9404612 Township Range Section <br /> WORK TO BE PERFORMED: /yowl4Q <br /> [X] NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ? B DESTRUCTION (choose type below) <br /> BSOIL BORING # 91) <br /> 0 Ci aOVER-BORE <br /> [X] WELL # MW17 to 95 ft. MW18 140 ft by Mud Rotary B PRESSURE GROUT <br /> "Other: Grout Specifications: Neat cement Grout <br /> COMMENTS: Conductor Casing on both wells, see Workplan dated July 5, 2006 and Addendum dated August 3, 2006 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X] MONITORING B HOLLOW STEM DIA. OF BOREHOLE 11 '/./ 6'/." MULTIPLE CASINGS? [X] YES ONO WELL CASING DIA6%/2" <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS F188/SCH 40 TYPE OF CASINGJX] STEEL(cond) [X] PVC(well) BOTHER:_ <br /> B VAPOR [X] MUD ROTARY DEPTH OF GROUT SEAL 81 /125 it TREMIE TYPE TO BE USED: 0 AUGERS [X] HOSE <br /> B AIR SPARGE B PUSH POINT GROUT SEAL PUMPED: [X] Yes p No ( NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> B SOIL BORING B HAND AUGER GROUT SPECIFICATIONS Neat cement grout over hydratedbentonite pellets <br /> B OTHER:.0 OTHER APPROX. BORING DEPTH 95/140 it [X] BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Yes ( if YES, list specifications here)F188 steel 65W <br /> "COMMENTS: Conductor casing in MW17 will beset to 80 feet conductor casing in MW18 will beset to 115 feet <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company CA Registered Geologst 6`795 Lee & Pierce Inc. <br /> Print Name John P. Lane Date t7 I Or•• (XP <br /> DEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE, ADDRESS : �1 ( amu- 41 <br /> WORK PLAN DATED: 440 all - 5 Zoe) <br /> i Qf� <br /> Application Accepted By Date Issued < 'v Area <br /> Grout Inspection By Date Final Inspection By Date <br /> IF <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # R C'D BY DAT I PERMIT I SERVICE REQUEST # INVOICE <br /> Of 5I 6 10 `ovaSgit 9 v <br /> C-57_ WC= WAIVER_ C- 57 Letter of Authorization to sfgn permit_ Encroachment doc AL# 1/25/02 <br />