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i <br /> SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ' #I 14 2010 <br /> SITE <br /> 600 East Main Street, Stockton;CA 95202- RIeN ���ppJTIGATION <br /> 1 _ . Telephone:(209)468-3454 Fax (209)468-3433 Web:www. �'�h1�UNIT IV <br /> 4 ... .-.:. ,P <br /> <IFORN -� ; V <br /> WELL PERMIT APPLICATION .. V Y I J <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 in 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 /> Sart.JeaA ul.L dovn+0 '.qh t-of-w°y Assessor's Vm �z9i <br /> Well Loo, on vq-9<} Cross Street E.Calimayma Rd. City Acampo Zip, 95220 Parcel# 495-143--02-- <br /> Property <br /> 95-143=02 ° <br /> Property SJ C—e fob I r✓ L:O 8% y8/O-/8/O E. i,zalfion RVe. sj'°Gk 9S a.ol <br /> Owner st Address 7 '.,�-,�-r;orescouri - City ware- Zip 95632 Phone#-209--X66—H40-- <br /> C-57 <br /> 09C-57 Contractor Gregg Drilling Address 950 Howe RoadCity Martinez Zip 94533 Lic# 57/(�5 Phone <br /> i Consultant/Sub Cntr ERI Address 601 N.McDowell BlvdPetaluma A/C10611383 <br /> City Lic#. Phone 707-766-2000 <br /> GIS Coordinates:X 38.2169018 Y -121.2687844 Township - Range Section I. <br /> WORK TO BE PERFORMED: _ <br /> 29 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# �'K °"r0 [I OVER-BORE DIAMETER k <br /> I �WELL# MW9 arid ElPRESSURE GROUT II <br /> [-I*OTHER - - GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD { <br /> COMMENTS: Encroachment Permit Attached <br /> I TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (('l l <br /> ®MONITORING El HOLLOW STEM DIA.OF BOREHOLE 8�� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA 2" �' I <br />( [I EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:0 STEEL IN PVC 0 OTHER <br /> 0 VAPOR '`Ji MUD ROTARY. DEPTH OF GROUT SEAL 67'and 125'TREMIE TYPE TO BE USED 0 AUGERS]HOSE <br /> 0 AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:N Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> j ❑SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS.. �I <br /> 0 OTHER: 0 OTHER: APPROX.BORING DEPT 9'O and 13 8 ' C_T' <br /> H BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> COMMENTS: < <br /> CONDUCTOR CASING PROPOSED (if YES.list seeGspecificationsncommemem section) <br /> I NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> f - 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS - <br /> III I hereby tfy Ina <br /> In tire prep ed is application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatto s, nd a I p licab alit nma Laws. <br /> Signed Title/Company Staff Geologist/Environmental Resolutions,Inc. <br /> Print Name David Daniels Date January B, 2010 <br /> R r� <br /> DEPARTMENT USE ONLY <br />! SITE MAP IN UNIT IV FILE,ADDRESS: 2 5.3 55 11. tin I{ Way 9 9 O. <br /> WORK PLAN DATED: Se o4 e Yri bt?ry�� <br /> APPLICATION ACCEPTED BY V i ct-nr�� L !YLC,L_(,r Y- f/ ET_ DATE ISSUED I - 19 -1O AREA I�S 4-Zo <br /> GROUT INSPECTION B617 <br /> Y 1nr'i n M,,_ rj'n2rk Z-LI10 FINAL'INSPECTION BY DATE -I _/O <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: r n O" S <br /> ACCOUNTING ONLY: AID# FAC# <br /> i PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3501 89. 0d 89IS- ro SR# 005r' s <br /> C-57 WC _ -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> i EHD 29-01 10/28/09 <br /> WELL PERMIT APP - - <br /> f <br />