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11 <br /> L:1 Li::�`� � " FILE COPY <br /> ,or s�In..o ` X009 *San Joaquin County <br /> RQiVIvU[I T i-119iftonmental Health Department SITE <br /> RMIT's'NwYast Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT Ib <br /> Wbv <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0713 <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 /> WELL Location 1600 Durham Ferry Road Cross StreetH�33 Cit Tracy 95376 Assessors <br /> Y Zip Parcel# 255-100-04 <br /> PROPERTY <br /> OwnerGeorge& Mei Teranishi 1600 Durham Ferry Road <br /> Address City Tracy Zip95376 phone# (209)835-3596 <br /> C-57 Contractor RSI Drilling Address 220 N. East StreetCityWoodlandZip Lic#802334 <br /> Phone# (530)668-2424 <br /> Consultant/Sub Cntr Geological Technics Inc. Address 1172 Kansas Ave. City Modesto Lic# N/A Phone# (209)522-4119 <br /> GIS Coordinates:X 31. 667- ,y 7 lz - ,3/, <br /> Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> IOrSOIL BORING#3 Geoprobes <br /> 0 WELL# 0 OVER-BORE. DIAMETER <br /> a PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: See Workplan dated 09/26/07 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS See Workplan dated 09/18/2008 <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLEW40, a MULTIPLE CASINGS 0MULTI-LEVEL WELL CASING DIA: 2 __ C <br /> 11 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR ��`0/0 MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: BADGERS 0 HOSE <br /> 0{UR SPARGE/OZONE I USH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIIyLIM FREE-FALL DEPTH IS 30') <br /> 3f,4OIL BORING / 0`HAND AUGER GROUT SPECIFICATIONS --V-etiY <br /> ( <br /> p OTHER:_o OTHER APPROX.BORING DEPTH _ 0 BOLTED TRAFFIC BOX or n STOVE PIPE <br /> COMMENTS: See Workplan dated 09/18/2008 CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. 4 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, R s a e ulations, an all applicable California State Laws. <br /> Signed x Title/Company <br /> /� <br /> Print Name �Lld1 Y)001 6-�/�(X Y1pU) L� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /6Oy <br /> WORK PLAN DATED: / q <br /> Application Accepted By Date Issued �/�/Z:5 O / <br /> ttt Area Q <br /> Grout Inspection By Date Final Inspection B3� Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PE=E/SERV;ICER7EQUESTINVOICE <br /> azl 1- � 11.2.5-4 SR <br /> C-57 ✓WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 FILE COPY <br />