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U0 San Joaquin County SEP <br /> m r. Environmental Health DepartmentN� 2�0) SITE <br /> 1ROP�� NTNE IGATION <br /> 600 E.Main Street,Stockton,CA 95202-3029 � <br /> M. (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ep <br /> 4M1T/SER 1110ES NIT-IV <br /> Well Permit'Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfor 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. <br /> Assessors <br /> WELL Location 25355 N Hwy 99 Cross Street 2...calim YMn'City Acampo Zip' 95220 parcel#.005-143-02 <br /> PROPERTY <br /> Owner MEEKS PAT H&K M 2006 TRUST.AddreSS 783 LOS Flores Court City Galt Zip 95632 Phone# ..1 act- 3GG...!!00 <br /> C-57 Contractor Cascade Drilling Address 3632 Omec Circle CItyR.CordovaZip 95742 Lloilt717510 Phone#916.638....1169 <br /> Consultant f Sub Cntr ERI .............Address 601 N. .McDowell.Blvd. Clty PetalumaL'Ic#A/c 1 -613-Phone#707.766.2000 <br /> GIS Coordinates:X 38.2169018 Y -121.2687844 ,Township Range Section <br /> WORK TO BE PERFORMED: <br />` p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> It SOIL BORING# 0 OVER-BORE. DIAMETER <br /> [I VVELL# MW6 n,i ytl-I Q PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> rhGv / <br /> pp r' '7) <br /> TYPE OF WELL INSTALLATION.TYPE CONSTRUCTION SPECIFI¢,A360 � g <br /> MMONITORING Q HOLLOW STEM DIA.OF BOREHOLE 12""a MULTIPLE CASINGS p MULTI-LEVEL WELL C SING DIA: <br /> IL <br /> 11 EXTRACTION Q AIR kiAMMERIDRlVEN CASING THICKNESS h.Sc . 4 0, ,TYPE OF CAS G: Il STEEL gPVC O OTHER: <br /> .. ...._._.. . <br /> I7 VAPOR a MUD ROTARY DEPTH OF GROUT SEALApprox. 156' 7}�EMI TYPE TO BE USED: WAUGERS a HOSE <br /> j p AIR SPARGE!OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: RY9s a No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> II SOIL BORING (I HAND AUGER GROUT SPECIFICATIONS port land cement slurry <br /> a OTHER: BOTHER Sonic APPROX.BORING DEPTH 17 0 'ali /�9 ff BOLTED TRAFFIC BOX or [I 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 Ordin nces, Rule and R ations,and all applicable California State Laws. <br /> Signed x Tltle/Company <br /> Print Name pa#a <br /> DEPARTMENT USE``ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:. •1$�$Jr r F7 W 4 <br /> I WORK PLAN DATED: I 2 <br /> Application Accepted By li&4y M e r Date lssued q..l)�) l<_. <br /> Grout Inspection By Vi P+7Y t G IILP_z4Atjdj5" Date ( j , Final Inspection By Date: <br /> Destruction Ins ecdon BX Deft: <br /> COMMENTS!aCONDIT10N5: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3501 A`8989. Gd a&43 L,,/07 9z! 07� SR# 00 2027 <br /> C-57— WC_,,_-WAIVER C-57 Letter of Authorization to sign permits Encroachment doc,,,_ <br /> EHD 29-02-001 web <br /> 6122/04 <br />