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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT --SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />�'J L fl 2 1 200911epboner (209) 466-3449 Fax: (209) 468-3433 Web: WWw.s' ov.or /ehd UNIT IV <br />ENVIRONMENT HEALTH i WELL PERMIT APPLICATION <br />PERf0J/KS RES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hareby nide to San Joaquin County for a Pemtit to mrrstnxt and/or Fatah the week described. This applczNon is trade in mmpliancewith Ban <br />Joaquin County Developmard Title, chapter 9-1115.3 and the Standards of San Joagun County Environmental Hea Nh DepartrtaM, <br />Well Location 75 haat Alpine Avenue Cross Street El Dorado street Stockton Assessor's <br />Property City Zip 95101 Pavicel# 115-1aD-D7 <br />Owner Guido D. Segarini Addraw Po lior lBSO CNY Apt.. Zip 95601 Phone# 831-689-9285 <br />C-67 Contractom.su,.de Drillioa. Inc Addross 3632 Osec Circle Cynnls10 <br />City Bmcho oosnlova tit# _phone 916-638-1169 <br />Consultant'Sub Cnlr E71C Rngiaeariag <br />GIS Coordinates: A <br />2295 ebrollo Ave. City Pteaaaat Gill l.ic# 624D22 plrone 925-602-6710 <br />Township 0211 <br />WORK TO BE PERFORMED: <br />® NEW W ELLSORING (CPT, GEOPROBE. HYDROPUNCH. HAND AUGER, OTHER') <br />Q SOIL BORING# <br />® WELL# 3 <br />[I.OTHER <br />Range D61? Sedion 34 <br />[]DESTRUCTION (CHOOSE ) YPE BELOV7) <br />❑ OVER4ME DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />(RI MONITORING OHOLLOWSTEM <br />DIA OFBORENOLE 1416 0MULTWLECASINGS[3MULTIiEVFL WEILGA511400IA =' <br />❑EXTRACTION ❑AIRHAMMERIDRNEN <br />CASING THICIOJESS Sch- 40 TYPE OF CASING ❑STEFL 19 PVC Q OTHER <br />CHECK # <br />between <br />❑ VAPOR ❑ MUD ROTARY <br />_ DEPTHOF GROUT SEAL 51'- 58'TREMIE TYPE TO BE USED 29 AUGERS [3 HOSE <br />O AIR SPARGEKIZONE O PUSH PONT (GP OR CPT)_ <br />GROUTSEAL PUMPED O Yes ®No(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HANDAUGER <br />GROUT SPECIFICATIONS Meet Sweat <br />❑OTHER _, []OTHER <br />APPROX BORINGDEPTH between 70'-75'® BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br />I ZZ c�j <br />co"LlerORC3tAIG Yea InrY3 Mmea6¢ionxm mmmmtsenm� <br />7tc:ED <br />COMMENTS'. 8-5/8' O.D_ steel conductor casing fro surface to 48' <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />4N WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />1 hereby cerfify that I have prepared this application and that the work mN be done I accordance with San Joaquin County Ordinances, Rules and <br />Requba s, applirabie California Laws. <br />Signed <br />Ti ia/CofnParry Operations Manager/ Cascade Dri-:ing, Inc <br />Print Name Tony Jaramillo <br />Data 01/16/09 <br />DEPARTMENT USEONLY `. <br />SITE MAP IN UNIT IV FILE. ADDRESS: ash L • <br />�' I <br />.r.... -. anp Y <br />WORK PLAN DATED: O2Tf�a b- �' LzI <br />SCO ii <br />APPLICATION ACCEPTED BY <br />DATE ISSUED L2 O AREA <br />GROUT INSPECTION BY (A nnA X0..4 <br />-L_ _II5'I0T FINAL INSPECTION BY«_�__ _ _ DATE Z o n <br />DESTRUCTION INSPECTION BY <br />DATE <br />COMM ENTSICONOITIONS: <br />ACCOUNTINGONLY <br />AIDE <br />FAC If <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMITISERVICE 0 <br />INVOICE <br />Z�ot <br />89.00 <br />SoI2� <br />(� <br />I ZZ c�j <br />SR# 5635 <br />C-57 " WC -WAIVER --057 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />EMD23U1 nrvo]tWcBl <br />ENCROACHMENT DOC <br />WELLPERMIT APP <br />