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� ) U FILE COPY <br /> quly San Joh4uin County <br /> z <br /> Environmental Health Department SITE <br /> w• { 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax:(209)468-3433 Web: www.sigov.org/chd UNIT IV <br /> uFORN Well Permit Application, <br /> 1001 JAS 9 PM 3• <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 app%pKjgn-Isfiad 6jdo(n�li6 vXth San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health ep@qt�M J ir'1j la'd f A L <br /> Lanthrop tiEALTNaS4eBstori�THENT: <br /> WELLLocation 15615 South 7th Street Cross Street L Street City Zip Parcel#. 1 <br /> PROPERTY PO Box 97 Lanthrop 95330 Phone# <br /> Owner James M. Langston Address City Zip.. <br /> C-57 Contractor Mitchell Drilling Address7900 Myrtle Ave City Eureka Zip,95503 Lic# 72617 Phone# 707-444-9040 <br /> - <br /> Consultant/Sub Cob Adv GecEnvironmenta)Address 837. S haw Road CityStoctkon Llc# Phone# 467-1006 <br /> GIS Coordinates:X _ ,Y ,Township Range Section <br /> { <br /> WORK TO BE PERFORMED: <br /> ANEW WELL I BORING (CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# .. n OVER-BORE. DIAMETER <br /> WELL# MW-9 V aPRESSURE GROUT <br /> p <br /> -Other DPE-1 " GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CO <br /> yINSTRUCTION SPECIFICATIONS 2-inch - <br /> IYMONITORING ft HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS E MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMERlDRIVEN CASING THICKNESS SCH 40 .TYPE OF CASING: Q STEEL [frPVC a OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 10/10 TREMIE TYPE TO BE USED: ffAUGERS a HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes so 'No (d Oe E nMMAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 5/25 <br /> 41b2 <br /> THER: DPE-1 a OTHER . APPROX.BORING DEPTH _ [KBOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED. NA (if YES,list specifications in comment section) <br /> COMMENTS: 1 MonitoringWell to 25 feet, 1. DPE to 25 feet <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 Ordinan l"andegulations, and all applicable California State Laws. <br /> Signed //�'� - Title/Company Vice President <br /> Print Name Robert Marty - Date 1-04-06 <br /> DEP ME,NNTi USE ONLY �f yz �SLb <br /> SITE MAP IN UNIT IV FILE,ADDRE v <br /> WORK PLAN DATED: V 7 <br /> Application Accepted By - _ Date Issued I--.��/ Area v� <br /> Grout Inspection By or Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE I O AMOUNT REMITTED CHECK# . REC'D BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> C-5 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> AN <br /> EHD 29-02-001 <br /> 6/12/04 - .. <br />