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/°` cap �✓ SAN JOAQUIN COUNTY FILE C <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> SITE MITIGATION <br /> elephone:(209)468-3449 Fax: (209)468-3433 Web:www.s' ov.or /ehd <br /> `7 j:1 ,zN. UNIT IV <br /> MAY WELL PERMIT APPLICATION ,/1'ti�a� <br /> �P��;'IEi(;\PviC HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pC(�'� ;/*5X�z <br /> Application iS-ht�iV ''eYo�sEn 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. OG <br /> Assessor's 1 v <br /> Well Location Harlan Road Cross Street East Louise City Lathrop Zip 95330 Parcel# '�`8-210-23 <br /> Property Richland Crossroads <br /> Owner Address _2220 Douglas Blvd Sutie 290 City Roseville Zip 95661 Phone# 916-782-3330 <br /> C-57 Contractor Cascade Drilling Address 3632 Omec Circle City Rancho Cordova Zip 95742 Lic# C57-717510 Phone <br /> Consultant/Sub Cntr Stantec Address 3017 Kilgore Road City Rancho Cordova Lic#654498 Phone 916-861-0400 <br /> GIS Coordinates:X 37?to Y —IZ-t- Z15 Township Range Section <br /> WORK TO BE PERFORMED: ?2-. 2 <br /> CK NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") El DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ®*OTHER Ozone Sparge Wells-SP-16 through SP-27 GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING N HOLLOW STEM DIA.OF BOREHOLE 8_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:0.75" <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SCH 80 TYPE OF CASING:❑STEEL N PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL "26'bgs TREMIE TYPE TO BE USED N AUGERS❑HOSE <br /> N AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes N No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 32'bgs ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: 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 <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appli ab lifo Laws. <br /> Signed Title/Company Associate Geologj5t/Stantec <br /> Print Name rad Shelton, P.G. Date 5-12-2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Q <br /> APPLICATION ACCEPTED BY D I� O AREA O <br /> GROUT INSPECTION BY FINAL INSPECTION B DATE Z (Jg <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE PERMIT/SERVICE# INVOICE <br /> 3501AsGJ kw �. `ZFO �a-Zo-o� R#Of 63 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT Or ENC5.Q H ENT DOC <br /> EHD2"1 11/5/07 d/c- <br /> � P <br />