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71 <br /> °Pul <br /> ca (.;ian Joaquin County <br /> Environmental Health Department SITE <br /> m. < 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:wwwsjgov.orgJehd UNIT IV <br /> a<)FoaN 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 /> ad <br /> Assessors <br /> 10842 S. Harlan Ro <br /> WELL location Cross Street Roth Road CityFrench Camp Lp 95231 ParcepF 1933028 i <br /> PROPERTY <br /> Owner Beneto, Inc. Address 4080 Seaport Blvd Cdy W. Sacto Zip 95691 PhoT# (916) 677-0817 <br /> CSTContractor V&W Drilling Inc Address P.O. BOX 970 CityLodi .Zip 95241tic 720904 Phone# (209) 369-9600 <br /> Consultant/Sub CntrLee & Pierce, Inc. Address 3800 McHenry Ste.IClty Modesto LiC#PG 6795 Phone# ( 0 ) 927-1247 <br /> GIS Coordinates:X__2_7.513065912 y.-121.164281378 ,Township Range Section <br /> WORK TO BE PERFORMED: i <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) VDESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# )WPRESSURE GROUT <br /> 0.Other - GROUT SPECIFICATIONS Neat Cement <br /> COMMENTS: Pressure grout wells MW-1 MW-2 MW-3 overexcavate to 3 feet with 24-inch-auger <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL g PVC g OTHER: <br /> VAPOR O MUD ROTARY DEPTH OF GROUT SEAL .. TREMIE TYPE TO BE USED: 0 AUGERS O HOSE <br /> AIR SPARGE)OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: B OTHER APPROX.BORING DEPTHL.0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> I <br /> CONDUCTOR CASING PROPOSED (d 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 J/""—f"b Title/Company Professional Geologist 6795 <br /> f <br /> Print Name John P. Lane Date 07/23/07 <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE,AD RESS: <br /> WORK PLAN DATED: 2/Z 5 &P-7 O <br /> Application Accepted By LJ ik,!w-c.-t - Date Issued W-3-067 Area 9917 <br /> 7 <br /> Grout Inspection ey Date Final Inspection By Date <br /> Destruction Inspection By Date t D <br /> COMMENTS/CONDITIONS: A--w A-w <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 7/3 07 SR#d0SI1/5-6 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization <br /> to sign permit_Encroachment doc_ <br /> ERD <br /> 35.0; )we ya <br /> 622/04 <br /> 1 i <br />