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�x � ED <br /> SAN JOAQUIN COUNTY <br /> �tP` ENVIRONMENTAL HEALTH DEPARTMEISMC 3 2009 SITE . <br /> w 600 East-Main Street, Stockton, CA 95202-3029 HENAhGATION <br /> Telephone:(209)468.3454 Fax:(209)468-3433 Web: PER ICES UNIT IV <br /> WELL PERMIT APPLICATION FILE COPY <br />' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I} Application is hereby made to San Joaquin County for a permit to wnstructandlor installthework described. This application is made in compliance with San <br /> 1' Joaquin County Development Title,chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department Assessor' <br /> JI} E.Calima a.Rd. City. .Acampo Zip 95220 Parcel t05-143-02 <br /> Well Location 25355 N.Hwy 99 ..Cross Street - Ym <br /> Property Pat Meeks,H&K 2006 Trust Address 783 Los Flores Court City Galt Zip 95632 . Phone# 209-366-1100 <br /> owner T26-313-5$00 <br /> C-57 Contractor Gregg Drilling Address. 950 Howe Road - city Martinez Zlp. 94533 IJo#- Sjb 7� Phone <br /> fi Petaluma A/C1061133 707-766-2000 - <br /> Coneut aMrSub CMr - ERI Address- 601 N.McDowell Blvd City Uc# hone <br /> GIS Coordinates:X 38.2169018 Y- -121.2687844 Township Range Section <br /> WORK TO BE PERFORMED: - - <br /> ®NEW WELUBORING(CPT,GEOPROSE.HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# MW8-X91+39- VM I-S-KJ C]PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> [3EXPLOSIVESDETONATING CARD <br /> COMMENTS: <br /> ' . <br /> � TYPEFQyUELL� INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i ®MONITORING LIHOLLOWSTEM - DIA.OF BOREHOLE _LL <br /> ❑MULTIPLECASINGS❑MULTI-LEVEL WELL CASING DIA: 2" <br /> f ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASINGTHICKNESS TYPE OF CASING:❑STEEL I%PVC ❑ OTHER <br /> Y .. <br /> - p VAPOR pQ MUDROTARY - DEPTH OF GROUT SEAL 67T- TREMIETYPE TO 8E USED 0 AUGERS❑HOSE , <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:N Yes ❑No(NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> - :O SOIL BORING ❑HANDAUGER GROUTSPECIFICAMONS ;4 <br /> D Id$N <br /> ❑OTHER: C3 OTHER: - APPROX.BORING DEPTH iB�andi3B� IN BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 'CONDUCTOR CASING PROPOSED' - (e YES.➢sl syacnrstibnc vncammeni seGimQ <br /> COMMENTS: - ._. <br /> �ry,q I.. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> { - 43 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> +I I hereby certlfy th ve pared s appiicatlo d et the work will he done I accordance with San Joequln County Ordinances,Rules and <br /> a a � <br /> ' Regulations,and I app"dable Cda Laws - �- <br /> { Signed 5 Title/Company Staff Geologist/Environmental Resolutions,Inc. <br /> Print Name Jordan M.Lewis - Date Dece;nber 22,2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ "S c <br /> 1 WORK PLAN DATED:_ SG+(Jtern6ef ir, ZO 9 <br /> 1 1 APPLICATION ACCEPTED BY Vj'&s ��lZY�hILN C e DATEISSUED I�IS�/O AREA 1459 <br /> GROUT INSPECTION BY Vi(�" aft' 1rl -FINALINSP CTION BY Vie-+,,1^;4Yheathzjj DATE 1 1Q:'Ib 10.1 <br /> I DESTRUCTION INSPECTION BY - - DATE { <br /> COMMENTS/CONDITIONS: r stQII,Qf;o O Y e SI'I- - <br /> ACCOUNTING ONLY: - AID# FAC# _ <br /> PE CODES FEE INFO AMT REMITTED CHECK# - RECV'D BY DATE PERMITISERVICE# INVOICE - <br /> I <br /> i <br /> 3.589. 00 99. 00 -zoo 3 �/�2 �-Is-ia sR#oos9lr,? <br /> i .. C-57 VJC WAIVER 057 LETTER OF AUTHORIZATION TO SIGN PERMIT - ENCROACHMENT DOC <br /> EHD2MI 1012am9 <br /> ,. WELL PERMIT APP <br />