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LOrGdp \Yj/IENT <br /> R rEIVF—D <br /> �Q <br /> Wf. SAN <br /> J <br /> OAQUIN COUNTY <br /> - FEB? 12 <br /> 2010 <br /> EWIRON MENTAL HEALTH,DEPARTMENT . <br /> SITE <br /> 600 East Main Street,Stockton,CA 95202-3029 SAN JbAQUIN COIGATION <br /> Telephone:(209)468-3454 F'aX:(209)458-3433 Web.,WWW_s' OV.5WI NMENT <br /> tF I=PARSMEN@NIT IV <br /> `WELL PERMIT APPLICATION <br /> NON-REFUNDABLg 12ERMIT EXPIRES 1 YEAR M DATE IS.51JED <br /> Application is hereby made to San Joaquin County for a permit to consMict andfor install the Work described. This applicationis 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 /> Wa1I Location 1805 Harbor St. Cross street S.Fresno Ave. Ci Stockton 85203 Assessor 14502005 <br /> Property <br /> tY = .Zip Parcel 0- <br /> Zip <br /> Newman Grain Corp, Address 1805 Harbor Street Cn Stockton zip 95243 .Phoned 209-4$2.6919 <br /> C-67 Contractor PeneCore Drilling Address 1238 Alice Street Sufte A City Woodland _ ,Zip 95776: Ltc fe 906899 Phone <br /> Cohsuttont(Sub CntrHUH&HUff,IM. Address 915 Harger Road Suite 330 City Oak Brook.tL '^ Lic NIA php� 630-684-9100 <br /> 1 North <br /> GIS Coordlnatea:X ,Y ,.Township Range 6 East Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLMORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION{CHOOSE TYPE SELOVV) <br /> ❑SOIL BORING* <br /> OVER-BORE DIAMETER <br /> ❑WELL# <br /> ©PRESSURE GROUT Neo Cement <br /> *OTHER GROUT SPECIFICATIONS.24M harp A fi Cof1 <br /> Gal FI9 <br /> ❑EXPLOSIVES.DETONATING CARD -- _- <br />[, COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CObMTRUCTION SPECIFECATIONS <br /> E [+ MONITORING El HOLLOW STEM DIA.OF BOREHOLE 8.3' <br /> f -...0 MULTIPLE CASINGS[I MULTI-LEVEL. WILL CASING'pIA:,2.(}" <br /> C7 EXTRACTION El AIR HAMMERIDRiVEN CASING THICKNESS 0.154" TYPE OF CASING:CI STEEL ®PVC ❑ OTHER'- <br /> 0 <br /> THER'_❑VAPOR ❑MUD ROTARY DEPTH OF GROVT SEAL. b TREMIE TYPE TO BE USED(3 AUGERS E3 HOSE. <br /> ❑AIR SPARGFJOZONE 0 PVSH POINT(GP OR CPn_GROUT SEAL PUMPED;IE]Yea ❑No (NOTE:MAXIMUM FREE•FALL DEPTH IS 307 <br /> ❑SOIL BORING ❑HANDAUGER GROUT SPECIFICATIONS <br /> f O OTHER: ❑OTHER; APPROX.BORING DEPTH "Sae Attached Logs❑BOLTED TRAFFIC BOX OR a STOVE PIPE <br /> UCTOR WING PAOED (if YES.rnt aveeiA=Wna In tanuneO lawn) . <br /> COMMENTS: See attached logs for ori i nal ConstI Wruction-1 n or a j on <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certHy that I have prepared this application and that the work will be done I accordance wl;h San Joaquin County Ordinances,Rulos and <br /> Regulations,and all a to Cattf a Laws. <br /> Signad TMefCompany x �� r-.•� :, ��r�� <br /> i. Print-Name / =...-. _ Date r�, <br /> i 4 / DEPARTMENT <br /> EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.ADDRESS: ``r <br /> f WORK PLAN DATED: A I [�C!/ V <br /> APPLICATION ACCEPTED BY DATE ISSUED 1 d. AREAL <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY �r p DATE. !v <br /> t COIMIMtENTSICONDI IONS: 6-,A,- 5&& <br /> Ci•C,.r I'�W <br /> ACCOUNTING ONLY: AID# FAG s <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D'BY DATE PERMITfSERVICE i INVOICE <br /> C-57 VJC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHII29Ot 19lz810 - WELL PERMIT APP <br />