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Pa v San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, C = ZO2MITIGATION <br /> ` L <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd- UNIT IV` <br /> Well Permit Application Y �00� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descdited.1T51opileatmn is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health CIirtment. j,c <br /> Assessors <br /> SAN COAQUIN COUNT'S AREA 12 KUNICI-PAL WELL r2 <br /> WELL Location Cross Street Mokulumne City Thornton Zip CA Parcel# �`�a `It1°�aJtaA� <br /> PROPERTY <br /> Owners'' COAQUIN COUNTY UTILITIES Address City Zip Phone# (209) 468-3090 <br /> GreggDrilling Address 950 Howe Ave City MartinezZip94553 Lic#485165 Phone# 925-313-5800 <br /> C-57 Contractor 55 5 <br /> Consultant/Sub Cntr Advanced c-eOErjyirCnmentai Address 837 Shaw Rd. City Stockton LIC# 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 1F NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) �DEST RU-BORE. ON DIAMETER(choose type below) <br /> 0 SOIL BORING# <br /> WELL4i MW-7 0 PRESSURE GROUT <br /> �*Other <br /> GROUT SPECIFICATIONS <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> .B MONITORING a HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:? <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCHD 40 TYPE OF CASING: 0 STEEL IF PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4' TREMIE TYPE TO BE USED: [[AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEA6?�ffEp iQlYNS 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 20' it BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: MW well is a monitorina well(21'diameter,4' rout,201total depth) . <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 Ordinances, Rules andr'Regulations,a.nd,_aLl_applicable California State Laws. <br /> Signed x Title/Company StaiL Ceoioaist/Advanced GeoEnvironmental <br /> Date n4 ?2 i08 <br /> Print Name Lauren Cardinalli <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:-�ho�Q <br /> WORK PLAN DATED: <br /> �'>�if1 <br /> Application Accepted By Date Issued Area <br /> I i <br /> Grout Inspection By / ✓ �1V <br /> Dated� L.l Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: o G <br /> VACCOUNTINGONLY: AID# FAC#EEINFO AMOUNT REMITTED CHECK# REC'D BY 7DA;TE PERMIT I SERVICE REQUEST# INVOICE <br /> S R#' ops 5`�Z <br /> '-57_ WC—WAIVER_ C-57 Letter of Authori,­2tion to sign permits Encroachment doc_ <br /> D 29-02-001 <br /> '/04 <br />