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Wan Joaquin County °Rj WE VELD <br /> Environmental Health Department 0 7 2009 SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.cWftMEHT HEALTH UNIT IV <br /> Well Permit Application AUGPERMIT/SERVIC€S <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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Hazelton & Stockton 95206 Assessors 147-120-08 <br /> WELL Location 375 W. Hazelton Ave. Cross Street Scotts City Zip Parcel# <br /> Sierra Lumber Manuf. <br /> PROPERTY 375 W. Hazelton Ave. Stockton 95206 209-943-7777 <br /> Owner c/o Bob Long Address City Zip Phone# <br /> Rancho 95742 717510 <br /> C-57 Contractor Cascade Drilling Address 3632 Omec Circle Oity ordova Zip Lick Phone# 916-638-1169 <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lick 680227 Phone#209-467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPS,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> Q WELL# MW-16/17/18/19/20 aPRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: See Monitoring Well Installation Work Plan, dated 06 May 2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 8 HOLLOW STEM DIA.OF BOREHOLE e" a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Sched. 40 TYPE OF CASING: a STEEL M PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 55' TREMIE TYPE TO BE USED: I9 AUGERS C HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 8 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> Q <br /> OTHER:_a OTHER APPROX.BORING DEPTH 70' It BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED We (if YES,list specifications in comment section) <br /> COMMENTS: See EHD-approval letter, dated 16 July 2009 <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 Ordi ances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x .1.a �= ` yJ�oG Title/Company Project Manager/A.G.E. <br /> n <br /> Print Name <br /> Timothy J. Cuellar Date 07 August 2009 <br /> DEPART V1IENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ���✓I—��f C��Ia �- <br /> WORK PLAN DATED: p <br /> Application Accepted By. &lt-Cp 4 Date Issued O 81 Area <br /> Grout Inspection By Date [ 0 g Final Inspection By Date Iff <br /> Date <br /> Destruction Inspection By <br /> COMMENTS/CONDITIONS LoF S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RE BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35 1 S iV3Yo� �2 foej �� D SR# DOSg000 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign p rmit_Encroachment doc_ <br /> ERD -oo $�t <br /> 3�1� 35� ®� 3a t>✓ <br /> 35x3 �o 5 <br /> 9/11/2007 , <br />