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,� I span Joaquin f�unty • FILE Copy <br /> Environmental Health Depart <br /> 304 East Weber Avenue, 3rd Floor, Stockton, n0�' SITE <br /> ,\ci MITIGATION <br /> , (209)468-3449 Fax: (209)468-3433 Web: wwwsjgov.orKehd� <br /> Well Permit ApplicationUNIT IV <br /> FES �lh <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT trasWApplication is hereby made to San Joaquin County for a permit to construct and/or install the work desc d. 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 Locatior II / Q / ,reef Stockton Assessors y� <br /> < / ll %fSTTCity Zip Parcel#— s'�-.C�� <br /> PROPERTY - <br /> OwnerEsformes Ranch Properti,­ress P.O. Box 239Trac - - <br /> City y Zip CA Phone# 209-463-2310 _ <br /> C-57Contractor V&W Drilling gddress P.O. Box 416 <br /> CityIsleton ZiP95641 Lic#720904 Phone# 915-777-41((0 Q - <br /> /J <br /> Consultant/Sub Cntr Kleinf elder, Inc. gddress 2825 E. Myrtle St.Ci Stockton <br /> ty Lic# NA Phone# 209-948-1345 <br /> GIS Coordinates:X ,Y ,Township Range.9 Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# <br /> WELL ,rte 0 OVER-BORE. DIAMETER <br /> "Other# 2 v ° ✓ /'�-� ' `�� 0 PRESSURE GROUT <br /> COMMENTS: <br /> GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Ix MONITORING HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL 9 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D:AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat cement w/4$ Bentonite powder <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH 80' 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <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 an egulations,and all applicable California State Laws. <br /> Signed x _ Title/Company� T <br /> Print Name — ` �����GGGGGG��,��r Date 1< <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ,r ZQ�S <br /> 675G`r <br /> WORK PLAN DATED: <br /> Application Accepted ByDate Issued 19/0& Area <br /> Grout Inspection By Date / Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES F'EE,I'N'F/O AMOUNTREMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> WAIVER_ C-57 Letter of Authorization to sign permit_Encr Ment doc_ <br /> EHD 29-02-001 _ <br /> 6/22/04 C� <br />