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o ° SAN JOAQUIN COUNTYA, D <br />R D 6 2009 <br />ENVIRONMENTAL HEALTH DEPARTM SITE <br />t 600 East Main Street, Stockton, CA 95202-3 IRUNf�1F(ti' ( HEALITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.s W4RICES UNIT IV <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 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 />Asses <br />Well Location 75 East Alpine Avenue Cress Street El Dorado Street Stockton Parcel 1 <br />City Zip 95204 Pafcel# 115-140-07 <br />Property <br />Owner Guido G. Segarini Address PO Box 1810 City Aptos Zip 95001 Phone# 831-689-9285 <br />C-57 Confracforcascade Drilling, Inc AddreSS 3632 Omec Circle C57-717510 <br />CltyRancho Cordova LIC# __Phone 916-638-1169 <br />COnsultantlSub Cntr ETIC Engineering Address 2285 Morello Ave. _ CitY Pleasant Hill LiC# 629022 phone 925-602-4710 <br />GIS Coordinates: X Y , Township 02N Range 06E Section 34 <br />WORK TO BE PERFORMED: <br />® NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />❑ SOIL BORING# <br />O WELL # <br />❑ 'OTHER. <br />2 groundwater extraction wells (EXI <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />extraction wells (VEW1, VEW2, VEW3) <br />TYPE OF WELL - INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING [a HOLLOW STEM DIA. OF BOREHOLE IO", 12 12� MULTIPLE CASINGS ® MULTI-LEVEL WELL CASING DIA: 211,4 n <br />M EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS SCh. 40 TYPE OF CASING: ❑ STEEL 29 PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL 16' , 31TREMIE TYPE TO BE USED ® AUGERS [R 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 [I HAND AUGER GROUT SPECIFICATIONS Neat cement <br />❑ OTHER: []OTHER: APPROX. BORING DEPTH 321,48- ® BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specilkadons In comment sector) <br />Signed <br />Print Name <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />that I haa �epared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />4 all sop I'e California Laws. <br />Title/Company <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: +S QIA!I A...i <br />WORK PLAN DATED: 4 -e --c. • 'Lm C W <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />I ILS <br />DATE ISSUED q14 /�S _ AREA / <br />FINAL INSPECTION BY-L�iIT,_-moo, T DATE <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES i <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMITISERVICE # <br />INVOICE <br />iqol <br />ky.o� <br />Sola( <br />kP <br />a 4 o <br />SR# SGITI <br />C -57 y WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />EHD 2401 11/5N7 (WEB) <br />ENCROACHMENT DOC <br />WELL PERMIT APP <br />