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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 NOV 1 9 2007MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orf t ONMENT HEALRUNIT IV <br />Well Permit Application tIVP�►EnRMIT/SERVICES <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 466 Moffat Blvd Cross Street S. Garfield Ave City Manteca Zip 95336 parcel# Z11 CLIO I!t <br />PROPERTY <br />Owner Tom Barbour <br />2382 Derek Ave City Atwater Zip 95301 Phone# (209)357-3167 <br />C-57Contractor Gregg Drilling Address 950 Howe Rd City Martinez Zip 94553 LiC#485165Phone# (925)313-5800 <br />Consultant/ Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd City Stockton LIC# 680227 Phone# (209)467-1006 <br />GIS Coordinates: X , Y , Township Range Secti <br />WORK TO BE PERFORMED: <br />8 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />D SOIL BORING # <br />Q WELL # DPE -1 <br />D *Other <br />COMMENTS: 1 dual phase extraction well to 32' bsg <br />p DESTRUCTION (choose type below) <br />D OVER -BORE. DIAMETER 1 <br />D PRESSURE GROUT 6 - <br />GROUT SPECIFICATIONS 6^ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING I[HOLLOW STEM DIA. OF BOREHOLE 10 D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: 4 " <br />B EXTRACTION <br />D AIR HAMMER/DRIVEN <br />CASING THICKNESS SCH 40 <br />TYPE OF CASING: D STEEL If PVC D OTHER: <br />0 VAPOR <br />D MUD ROTARY <br />DEPTH OF GROUT SEAL 13' <br />TREMIE TYPE TO BE USED: V AUGERS D HOSE <br />D AIR SPARGE/ OZONE <br />D PUSH POINT (GP or CPT)GROUT SEAL PUMPED: D Yes <br />D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D SOIL BORING <br />D HAND AUGER <br />GROUT SPECIFICATIONS Type <br />I/II Portland cement <br />D OTHER: <br />D OTHER <br />APPROX. BORING DEPTH 321 <br />D;BOLTED TRAFFIC BOX or D STOVE PIPE <br />CONDUCTOR CASING PROPOSED no (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 <br />County ( <br />Signed <br />Print <br />tify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />inances, Rull"nd Regulations, and all applicable California State Laws. <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: to <br />Title/Company Staff Scientist/AGE <br />11/16/07 <br />DEPARTMENT USE ONLY <br />� -% ... - �'� 0 <br />Application Accepted ByDate Issued t l 1 2_010 Area <br />Grout Inspection By l.L n..ctn.. Date I Final Inspection By Date I v <br />Destruction Inspection By Date <br />COMMENTS/CON <br />ACCOUNTING ONLY: AID# FAC# <br />1 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PER QUEST # <br />INVOICE <br />35d ► <br />0 3 <br />-a0-2 <br />aaH.o' <br />353'o� <br />S5 3-- <br />I1'Zv�o� SR# 005 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permits Encroac n oc_ <br />EHD 29-02-001 <br />6/22/04 <br />W_ <br />