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San Joaquin County <br /> Environmental health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)4621-3433 Web: www•.sgov.orMAN 28 AH iO-'LMIT IV <br /> Well Permit Application SAN JonQUIN COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL <br /> Application Is hereby made to San Joaquin County for a permit to tonna and/or install the work descrOe fit aTppil lop s made in compliance with San <br /> Joaquin County Development Tide,Chapter 9-7115.3 and Gla Standards of San Joaquin Caurty Erwirormental Health Department <br /> WELL Location 20500 Holly Drive Cross Streat City Tracy Zip 95376 Assessors <br /> ssess rs <br /> OwnZ%preckels Sugar Company Address 20500 Holly Drive tib Tracy Zip 95376 phohe# (209)835-3210 <br /> C-67 CortradorSpectrum Exploration,IneAdd ass 2365 Wigwam Drive City Stockton Zip 95205 Lie# 512268Phone#(209)465-8712 <br /> Consultant/ale Cnlr Trihydro Corporation A4ldrsas 1252 Commerce Drive City Laramie Use phare# (307)145-7474 <br /> GISCwrchnates x_ .y ,TownsHp_2S Ra e 5E <br /> rg _ Section 16 <br /> WORK TO BE PERFORMED: <br /> N N EW WELL/BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> DSOILBORNG# DOVER-BORE DIAMETER <br /> N WELL#__MW-FOL:MW-FO2:MW-F03 D PRESSURE GROUT <br /> [)'Other_ GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M MONITORING M HOLLOW STEM DIA OF BOREHOLE 8" (]MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DLA:_ <br /> 11 EXTRACTION (]AIR HAMMER/DR NEN CASINGTH"NESS 2" TYPE OF CASING D STEEL $PVC D OTHER. <br /> 11 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 15' TREMIE TYPE TO BE USED. $AUGERS II HOSE <br /> D AIR SPARGE!OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED Z Yas D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> D$OIL BORING D HAND AUGER GROUT SPECIFICATIONS 7.5 gal Water to 94lbs cement <br /> [IOTHER DOTHER_____ APPROX.BORING DEPTH 258 _ _ --- $BOLTED TRAFFIC BOX or (]STOVEPIPE <br /> CONDUCTOR CASING PROPOSED No _ (if YES,list speclfcabons 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 Sari Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x _ �`t __ TRIe/CanPenY Trihydro Corporation <br /> _— <br /> PnntName Simona Tanaseseu Cale 6/3/05 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C✓ktr '12CIj /S ------ <br /> -,-D (�� Q�a <br /> Applicalan Accapted 8� // Date . �� Area <br /> Grout inspection By _ Nte7 �S t O b Final Inspection By __ Data <br /> Destruction Inspection By Date <br /> COMMENTS I CONDIT Af .✓h - ,r,,w..-aS <br /> ACCOUNTING ONLY AID# FAC# <br /> PECOOES FEEINFO AMOUNT REMn'TED CHECK# RECO BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> d`lel ���o �Saa IYD,73 /J/<, 61;- d� SR#� 79 <br /> C-57 WC.---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EM 29-02.001 <br /> 6/2104 <br />