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COMMENTS / CONDITIONS. <br />J?,:r <br />')DES FEE INFO AMOUNT REMITTED <br /> Area / 451 <br />ate " So --o 7 <br />FACA <br />DATE RECD BY CHECK* CE REQUEST* <br />WORK PLAN DATED: (.1kj 0 r? <br />) A <br />Application Accepleo By V4 catty -v-4y <br />Inspection <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 `;--S-- H <br />Date Issued <br />Grout Inspection By qjt 4-121' :4 kal.6, Date JO ro 7 Final Inspection By <br />Onte <br />50 4'81 89 0 ,0 <br />C-57 WC _-WAIVER C-57 Letter of Authorization to sign permit <br />END 29-02-00Iweb <br />6/22/04 <br />oachment doe <br />REcEll uz-; [,711D, <br />sEp 0 2007 <br />ENVIRoivA,IEN .r <br />600 E. Main Street, Stockton, CA 95202-3029 P ERMIT/SE* - <br />(209) 46R-3449 Fax (209) 468-3433 Web: www,sjgov.org/elid ;- <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 and/or install the wOra Oeschbed. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 arid the Standards of San Joaquin County EnVironmental Health Department. <br />Assessors <br />WELL Location_ 25355 N Hwy 99 Cross Street 2 Cal imiyrna City Acampo Zip 95 2 2 0 Prime* D 0 5 -14 3 - 0 2 <br />PROPERTY <br />Owner MEEYS PAT HOC M 2006 TRUST Address 783 Los Fic•les Court City Galt Zip 95612 Phoneir_ <br />C-57 Contractor Grego YJxiiiinq Address 9S0 Howe Road City Martinez Zip 94553 Lk:o4853-65 phones 925,1.13,5800_ <br />Consultant! Sub Cntr £21 Address 601N. 14.5:4;ov:ell Blvd.,. City petaiuma Lic#Afc lc:- 611.3a.i phone# 70? . '766 . 2000 <br />GIS Coordinates: X 38 • 2189018 -121 .2687E344 Townsnip_ Range Section <br />WORK TO BE PERFORMED: <br />fINEW WELL I BORING E,'PT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER'i g SOIL BORENG* CPT2 a 0 aLe PT- 3 <br />WELL <br />"Other <br />COMMENTS: <br />TYPE OF WELL <br />fj MONITORING <br />a EXTRACTION <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a HOLLOW STEM DIA, OF BOREHOLE2 . 25"a MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: <br />O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: I] STEEL 0 PVC a OTHER: <br /> <br />VAPOR a MD ROTARY DEPTH OF GROUT SEAL ' TREMIE TYPE TO BE USED. a AUGERS g HOSE <br />a AIR SPARGE/ OZONE gPUSH POINT (GP or CPT)GROUT SEAL PUMPED. 'Yes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING Ei HAND AUGER GROUT SPECIFICATIONS Cement grout.: w/ <5% pure sothum benconite <br />OTHER: J) OTHER APPROX. BORING DEPTH 14 0 ' fl BOLTED TRAFFIC BOX or 1:1 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 />; <br />I hereby waft Mat I nave prep d this application and that the work will be done in accordance with San Joaquin <br />County -L. ' vies a • F. • tions, and all applicable California State Laws. <br />II <br />Signed x ,._ Tele/company iffij 14. On 1 1/ i(j <br />Print Na me., a-A„ d (2---/ \. Date <br />ORIGINAL <br />San Joaquin County <br />Environmental Health Department ITE <br />ATION <br />IT IV <br />DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFiC.',ATIONS