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0 r . 1, • FILF COPY �y <br /> o �o San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sigov.org/6hd 1 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l w O t V <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 /> 16 EAST HARDING WAY Assessors <br /> WELL Location Cross StreetCENTER STREETCity STOCKTON Zip 95204 parcel#`39-020-01 <br /> PROPERTY 4108 BALLARD DRIVE MODESTO 95356 <br /> Owner PAUL GOSAL Address City Zip Phone# <br /> C47 Contractor BOART LONGYEAR. Address 510 5TH STREET city COLUSA Zip 95932 LIc#694686 phone#.562-906-1960 <br /> Consultant/Sub Cnt,SECOR INTER, INC . Address 3017 KILGORE:RD .City RANCHO Ltce NA Phone# 916-861-0400 <br /> .29465, 37.970,4203603 �UHUOV•C <br /> GIS Coordinates:X'121 649796 Y 67 ,Township 1 NORTH Range 6 EAST Section 3 <br /> WORK TO BE PERFORMED: <br /> ]NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> Q SOIL BO IN uV B OVER-BORE. DIAMETER <br /> a WELL#_ 0 PRESSURE GROUT <br /> Q-Other GROUT SPECIFICATIONS <br /> COMMENTS: DMW4 AND DMW-5 will be advanced using a sonic drilling rig equipped <br /> with dn0 lame er eayy-wa act down-hole casino to a total deathof lb teet.baS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 8.25 Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:2 INCH <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS SCH.40 TYPE OF CASING: B STEEL )Q PVC B OTHER: '.. <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS B HOSE <br /> Q AIR SPARGE/OZONE B PUSH POINT(GP or CPT)GROUT SEAL PUMPED: JkYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: O:OTHER SONIC APPROX.BORING DEPTH 75 FEET II BOLTED TRAFFIC BOX or Q STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: During advancement, Soil sampleS Will be collected continuously using a 20-foot core barrel '.. <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 Title/Company SECOR INTERNATIONAL INCORPORATED <br /> Print Name MICHAEL SPERBER _ oats o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted ey Date Issued__I" / " Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> BE CODES FEE INFO AMOUNT REMITTED J,SHE % REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O j03\22 t W SR# 053 me 1 _ <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to Sign <br /> /ppeerrml Encroachment doc <br /> BHD29-02-001 WEB <br /> 9/11/2007 <br />