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r <br /> L) <br /> e �:F SAN JOAQUIN COUNTY �� <br /> ENVIRONMENTAL HEALTH DEPARTMETE <br /> 600 East Main Street,Stockton;CA 95202-302$/(/L ATION <br /> Telephone:(209)4683454 Fax:(209)468-3433 Web: ov.or h7 OUIU UNIT IV <br /> WELL PERMIT APPLICATIOtrIEN THFA O P Y <br /> E <br /> V1 <br /> /SR <br /> o NON-REFUNDABLE PERMR EXPIRES t YEAR FROM DATE ISSUED. CF`� <br /> y <br /> plies' It is hereby in to an Joaquin County for a Perm#te conshud and/or install the work descnbed. Tnis app®cation Is Trade Incompliance w11h San <br /> JYr°� Joaquin County Devel Tllle,chi ter 9-1115.3 and the Standards of Son Joaquin County Environmental Health Depanment. V 7�z 9//� <br /> SonJoaR0;. C.,.nT nT_.- Jgy - Assessors _ <br /> wen Lo do _ Cross Street E.Calimayrna Rd. City- Ace�m o —. zip 95220 Parcel.#-moa--i4-3, <br /> ProPatY SJ eP e v •z-Works P.o�LioX r8/o:r8ro E.Hgzel-bn�-GGalt t.ockir� xUy 000 <br /> Owner_. tievuo crust Atltlress-=ry}�' 'CitY P . Phon'♦AK__. <br /> C-57 Contreaor Gregg Drilling Address 950 Howe Road'- qty Martinez _. Zp 94533 UG ,3i Phone <br /> A/C10611383 -'`'a"`5' <br /> ConsultanIfSub Cntr ERI, - Address 601 N.McDowell Blvd City Petaluma Lic# .Phone._.707-766-2000 <br /> j GIS Coordinates:X 38.2169018., Y -121.2687844 ,Township_ _ , Range_. _, Sectlon <br /> WORK TO BE PERFORMED <br /> I ❑NEW WELUBORING(CPT GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER•) C3}ppESTRUCTION(C NOOSE TYPE BELOW) <br /> O SOIL BORING# �OVFR-BORE DIAMETER <br /> e'er_ <br /> []-OTHER. <br /> -OTHER - -7) 1- GROUT SPECIFICATIONS nes cemen <br /> - _ -- ❑EXPLOSIVES DETONATING CARD <br /> i' COMMENTS. Encroachment Permit Attached <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' <br /> ®MONITORING ❑HOLLOW STEM .,. DIA.OFBOREHOLE QQV E)MULTIPLE CASINGS O MULTI-LEVEL WELL CASING VIA: <br /> E3 EXTRACTION 13 AIR HAMMERIORNEN CASING THICKNESS g _TYPEOFCASING:O STEEL INPVC ❑ OTHER v <br /> j OVAPOR 12 MUD ROTARY. .... ...... . . DEPTH OF GROUT SEAL I46 TRMIE 14'E TORE USED O AUGERSX1 HOSE tT' <br /> O AIR SPARGE/OZONE O PUSH POINT(GP OR CPT)_GROUT SEAL PUMPEDg1 Yes O No MOTE:MAXIMUM FREE-FALL DEPTH IS 307 <br /> I-]SOIL BORING [3 HAND AUGER_ .;GROUT SPECIFICATIONS tJC rnG ... .. J, <br /> 1 <br /> 1 ❑OTHER: (]OTHER: APPROX.BORING DEPTH �- r /'fO vO BOL ED /C BOX OR [I STOVE PIPE <br /> - CONDUCTOR CASING PROP ED - ofYEe,W.Petl.a In mmmmreegke,) <br /> .COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT;PERMITS', �c <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS L5 <br /> 1 <br /> 1 hereby certify that 1 have prepared this application and that the work VAN be done I accordance With San Joaquin County Ordinances,Rules and <br /> Regulations and ll-aPit,11 ble Catllntal§w's. <br /> Signed f _Tlde)Company . Staff Geologist/Environmental Resolutions,Inc. <br /> Pdnt Name Tracy 7.outsch. - we omydar _ _ <br /> 2�) Zo1U <br /> DEPARTMENT USE ONLY `� 7AL_ <br /> -: - <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: .....N A ...//..++_�� y. <br /> I - .APPLICATION ACCEPTED BY V i C-�-h Y I Q tyLG.ILLI- tt E4 DATE(ISSLUED .....39 .AREA�q <br /> ! - GROUT INSPECTION BY Y FINAL INSPECTION BY V4GC1 rnd&T' -_na,. DATE - <br /> I DESTRUCTION INSPECTION-8.Y. SII elk,: InG ✓�t�t Gc, DATE 1 8 -10 - /n^ <br /> COMMENTS/CONDITIONS 1�Y.-S�YU I.O+-t OT MY a- ? , G_ V by r r-L,O f- <br /> _4 <br /> -..._.._.............. ......_... _ <br /> ACCOUNTING_ ONLY. AID# FAG#_ <br /> PE CODE5 FEE fNFO AMT REMITTED CHECK# RECVD BY DATE PERMITISERVICE# ffNVOICIE - <br /> _ <br /> 3501 <br /> _GO,00 GO. 00 �o4Z l/tfn 7L /0 .SR#0040c30 <br /> ',)D-57_WC �-WAIVER ._....._.... ... . C57 LETTER OF AUTHORIZATION TO SIGN PERMIT --.ENCROACHMENT DOC - <br /> - EHD29-0110/28/09 WELLPERMITAPP <br /> r <br />