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SAN JOAQUIN COUNTY <br />"' ENVIRONMENTAL HEALTH DEPARTMENT F'-9}-j� SITE <br />�_,� <br />600 East Main Street, Stockton, CA 95202-3029 R�CFf �GATION <br />µ (209) 468-3449 Fax: (209) 468-3433 Web: www.s' ov.or / �IT IV <br />JUL 0 8 2009WELL PERMIT APPLICATION ti NVRo 9� <br />STH NMF ot,lo <br />ENVIRONMEENTHEG�I�EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Fp411 �v y <br />Application is here RJ`ICounty for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, chapter 0,1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Well Location Map Attached Cross Street ArCh Road AssessorsZ�� (opD3 <br />City Manteca zip 95336 Parcel # <br />Property Re ublic/Allied <br />Owner P Address 1145 W. Charter Wy. C;tyStockton zip 95206 Phone # 800-204-4242 <br />C-57 Contractor SD Drilling Address P.O. Box 1818 City Ramona Lic # 81936$hone 760-789-4935 <br />ConsultanVSub Cntr SCS Engines S4ddress3117 Fite Cr. #108 City Sacramento Lic # Phone 916-361-1297 <br />GIS Coordinates: X 37.88194 Y -121.19278 Township Range Section <br />WORK TO BE PERFORMED: <br />❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />WELL # TT FY; Extraction on W 1 1 — 6 Ra_ ❑ PRESSURE GROUT <br />❑ *OTHER _ GROUT SPECIFICATIONS <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 3611 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 611 <br />[EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS SDR 11 TYPE OF CASING: ❑ STEEL ❑ PVC [X OTHER HDPF. <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL 21 TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes C9 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />❑ SOIL BORING Cl HAND AUGER GROUT SPECIFICATIONS EliMtonite <br />❑ OTHER: [XOTHERBi7Cket Mcler APPROX. BORING DEPTH 501 ❑ BOLTED TRAFFIC BOX OR [-]STOVEPIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />,5 <br />I hereby ertify at I ve prepar this app ati an t at th work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulat' ns, a all a plicable s. <br />Signed Title/Company Vice President, SCS Engineers <br />Print Name Ambrose A. McCready, P.E. v Date -7/1 r) <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY ►�� DATE ISSUED <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />FINAL INSPECTION BY <br />DA <br />AREA <br />DATE p y <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />I INVOICE <br />-1 A o <br />SR# , ..579 / 7 <br />C-5/ <br />_ WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE MIT <br />EHD 29-01 11/5/07 (WEB) <br />ENCROACHMENT DOC <br />WELL PERMIT APP <br />