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SAN JOAQUIN COUNTY <br />�o <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />c { Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />SITE <br />MITIGATION <br />UNIT IV <br />MAY 1 WELL PERMIT APPLICATION / <br />�i'dtt ► i HEALIx NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />E�1\JICCfi��rp vG tt CCC It"IX1Z- <br />A Iicatiori i5 hLi'd6Y( S'eto� San Joa uin Count fora ermit to construct and/or install the work described. This a lication is made in compliance with San <br />PP Y q Y P PP P <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Well Location <br />Harlan Road <br />Property <br />Owner Richland Crossroads <br />Assessor's 170 <br />Cross Street East Louise City Lathrop Zip 95330 Parcel # 9M-210-23 <br />Address 2220 Douglas Blvd, Sutie 290 City Roseville Zip 95661 Phone # 916-782-3330 <br />C-57 Contractor Cascade Drilling <br />Address 3632 Omec Circle <br />CityRancho Cordova <br />Zip 95742 Lic # C57-717510 Phone <br />Consultant/Sub Cntr Stantec <br />Address 3017 Kilgore Road <br />City Rancho Cordova <br />Lic# 654498 Phone 916-861-0400 <br />GIS Coordinates: X 37 Tio <br />Y —IZ-Il. Z45 , Township <br />Asw I w <br />Range Section <br />WORK TO BE PERFORMED: <br />® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />❑ SOIL BORING# <br />❑ WELL # <br />®*OTHER Ozone Sparge Wells - SP -16 through SP 27 <br />COMMENTS: <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING IN HOLLOW STEM DIA. OF BOREHOLE 8" [:]MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 0.75" <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS SCH 80 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL —26 'bgs TREMIE TYPE TO BE USED ® AUGERS ❑ HOSE <br />® AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ® No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER <br />[]OTHER: ❑ OTHER'. <br />COMMENTS: <br />GROUT SPECIFICATIONS Neat Cement <br />APPROX. BORING DEPTH 32 ' bgs ® BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <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 />I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all appli ab lifo Laws. <br />Signed Title/Company Associate Geologist/Stantec <br />Print Name rad Shelton, P.G. Date 5-12-2008 <br />/ DEPARTMENT USE/ONLY D _ L P <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY iEK�f "— _ DATOG��,�=X,-��AREA <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />FINAL INSPECTION BY <br />DATE <br />7 <br />DATE,��e5-�-r <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE DICE <br />iso I <br />Asw I w <br />S7. <br />`ZFD <br />!o-Z0,0e R# DS 635 <br />C-57 V WC Ae I -WAIVER <br />EHD 29-01 1115/07 <br />C57 LETTER OF AU I HURILA I IUN I U SKIN HEKMI I r <br />tNC:tIV I UUI: <br />^_WELP <br />