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SAN JOAQUIN COUNTY ' EECEWEFI <br /> ENVIRONMENTAL HEALTH DEPARTMENTDEc - 7 200'F SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 WIGATION <br /> I 6� 71/ Tele hone:(209)468-3449 Fax.,(209)468-3433 Web:www.siGtH,,orDt�#p1T HEALTUNIT IV <br /> WELL PERMIT APPLICATION rERM)TISE" <br /> oy <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 liance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 2151 Country Club Blvd /9999 e,/ Stockton 95205 AsseSsora123-080-3b <br /> Well Location Cms,Street City Zip Parcel# <br /> Property C6 U-O pp Box 1962 Manteca ZIp 95337 Phone# 209-823-1400 <br /> Owner Roger Hartley Address City <br /> C57 Contractor Cascade Drilling Address 3632 Omec Circle C,-Rancho CordovaLlc# 938110 Phone 1-916-638-1169 <br /> Advanced GeoEnvironmental Inc. 837 Shaw Road �"YY Stockton 1-209-467-1006 <br /> Consultant/Sub CnV�,—f Address City Uc# Phone <br /> GIS Coordinates:X t*.%t0 'y <br /> —LZI • t (p .Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# C]OVER-BORE DIAMETER <br /> ❑WELL# DPE- an -2 ❑PRESSURE GROUT <br /> ❑-OTHERGROUT SPECIFICATIONS <br /> COMMENTS:__ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 91 HOLLOW STEM DIA.OF BOREHOLE1011 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4" <br /> ®EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL 19 PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL " -5' TREMIE TYPE TO BE USED❑AUGERS O HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ®No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> Cl SOIL BORING ❑HAND AUGER GROUT SPECIFlCA noNS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (I YES.IN q*dfl aeorre h mmmem seaiml <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 'here <br /> a py that i ha red this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Re9ul ns, d all ap icableCaliforniaLaws. <br /> Signed �__.. T'lllelCompany OPS Mgr/Cascade Drilling, L . P. <br /> PrintName Paul Snelgrove Date 12/01/2009 <br /> DEPARTM/ENNJT�USE ONLY „D—evF <br /> SITE MAP IN UNIT IV FILE,ADDRESS: e <br /> �± <br /> WORK PLAN DATED: !2- �� 0,F <br /> APPLICATION ACCEPTED BY 09 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION ^__r DAT <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# _ FAC# <br /> PE CODES I FEE IN O AMT REMITTED CHECKS RECV'D BY ERMITISERVICE# INVOICE <br /> �✓� Co��: Iz R#�.� <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> END za-o, ,,,soy twt:a/ FILE C O P l L�r APP <br />