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' <br /> PaU(N tan Joaquin Coun'ty <br /> z Environmental Health ] ment SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9 VIR 1200 <br /> 87 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> q�JFORN�P Well Permit Application <br /> EfIVIR�?f���1 T !T <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. p 3�0 <br /> UC.-2s Assessors �I� 2-3 <br /> WELL Location Harlan Road(APN Cross Street East Louise Ave. City Lathrop Zip 95330 Parcel#_a242+e-Ze- <br /> PROPERTY <br /> Owner Richland Crossroads LP Address 2220 Douglas Blvd.,Suite 290 City Roseville Zip 95661 Phone#_(916)782-3330 <br /> C-57 Contractor Cascade Drilling Inc. Address 3632 Omec Circle City Rancho Cordova Zip 95742 Lic# C57-717510 Phone#_(916)638-1169 <br /> Consultant/Sub Cntr SECOR International Inc. Address 3017 Kilgore Rd.,Suite 100 City Rancho Cordova Lic# 654498 Phone#_(916)861-0400 <br /> GIS Coordinates:l4AJ- 314167- ifiAgc 4Z•yy; Township Range Section <br /> WORK TO BE PERFORMED: <br /> pq NEW WELL( BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') [x]DESTRUCTION (choose type below) <br /> Q SOIL BORING# [X]OVER-BORE. DIAMETER 10" <br /> [X]WELL# MW-14 0 PRESSURE GROUT <br /> Q*Other <br /> p GROUT SPECIFICATIONS <br /> COMMENTS: O !�//�T/'/ &yeee'. &ezr A�rXVC,0 7eA) &//,0" <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X]MONITORING [X]HOLLOW STEM DIA.OF BOREHOLE 10 'a MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 2" <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: Q STEEL [X]PVC a OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 3 ft bgs TREMIE TYPE TO BE USED: [X]AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes [X]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Portland Neat Cement <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH 21 ft.bos. [X]BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 Ordinance , Rules and Regulations, a all applicable California State Laws. <br /> Signed x Title/Company Project Geologist/SECOR International Inc. <br /> Print Name Cohn O'Donnell Date 3/12/2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 14 �a -� `35,Z6 <br /> WORK PLAN DATED: /—lo - 200 6 <br /> Application Accepted By Date Issued~ga&" Area vfJ <br /> 6 <br /> ALXAFWN AL as <br /> Grout Inspection By Date Final Inspection ^ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> [ACCOUNTING ONLY: AID# FAC# <br /> E CODES FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> 5o3_/3 SR# 00;9000C) <br /> C-57 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ <br /> �ttud GtsG D-"`'f <br /> ERD 29-02-001 <br /> 6/22/04 <br />