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►N San Joaquin County • <br /> z4� �„Environmental Health Department SITE <br /> 44 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> 6 200(209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> R Well Permit Application <br /> LLj ;T;'SC�VICE NOWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApplicatWA 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 /> JoaquinL6ounty Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Woodbridge Road Woodbrid e, CA Assessors <br /> WELL Location 19720 North Benedict Drive Cross Street CityWoodbridge, Zip ,95258 Parcel# 01521060 <br /> PROPE10( t'gl0 ✓ AZiC-CDA/ AOE Sipe0�- j (” <br /> Owner '-Address City ZEN V2 Phone# <br /> C-57 Contractor Cascade Drilling Address3632 Omec Circle City C:ordcva Zip95742 Lic#932633 phone#(916)638-1169 <br /> Consultant/Sub Cntr ECOLOGIC Engineering Address 3520 Brookside Rd#141 City Stockton Lic# Phone#(209)242-0292 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL! BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL#PMW-5 PMW-6. PMW-7 g PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: iu l L4 P -� /_„_ .`-��d1- ` -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:d- /P4� <br /> a EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS Sci, 46 TYPE OF CASING: U STEEL , 'PVC 0 OTHER: <br /> a VAPOR MUD ROTARY DEPTH OF GROUT SEA TREMIE TYPE TO BE USED: D AUGERS B HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ,yNo (NOTE)): MAXIMUM FREE-FALL DEPTH IS 30') <br /> g SOIL BORING I1 HAND AUGER GROUT SPECIFICATIONS.,V\� <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTP-- OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PE'RMP-rQ <br /> 48 WORKING HOURS NO T iCE 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 x °'�' Title/Company g <br /> Cascade DrillingInc <br /> Print Name Tony Jaramillo Date 6/10/09 <br /> T <br /> C,): DEPARTMENT USE ONLY 6'3 <br /> SITE MAP IN UNIT IV FILE,ADDRESS; I 111-0 <br /> WORK PLAN DATED: '' %ri✓� <br /> Application Accepted By r, / r Date Issued (J'/� Area <br /> Grout Inspection By Date �/a` 0rFinal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONL'r AID# I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# ( REC'D BY DATE PERMIT/SERVICE REQUEST# I INVOICE <br /> E�t, SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> oi22/04 <br />