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= "I SAN JOAQUIN COUNTY `� BILE COPY A. EDD ENVIRONMENTAL HEALTH DEPARTMENT SITE 010 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.or4/ehd UNIT IV O ��F RN� ENVIRONWNT HEALTH WELL PERMIT APPLICATION PERMIT/SERVICES 6111NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Well Location 401 E. French Camp F cross Street Ash Road c; French Cam 95231 Assessors ty p Zip Parcel# 19314013 Property Address 3401 Crow Canyon Rd San Ramon 94583 Owner ss Y City Zip Phone# 925-415-6381 C-57 Contractor ECA Address 3011 Twin Palms Dr. City Aptos Lic# 69597 Phone 831-662-8178 Consultant/Sub Cntr Stantec Consulti Address 3017 Kilgore Road Suite 1C city Rancho Cordo Lic# Phone 916-861-0400 GIS Coordinates:X 37.881 Y -121.267 Township 715 Range RGE Section 14 WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) ®SOIL BORING# :i I irPrt Nash Soil Hnnnns ❑OVER-BORE DIAMETER ❑WELL# elQ�p�L2 [IPRESSURE GROUT El*OTHER d%� Q f/ GROUT SPECIFICATIONS COMMENTS: + I TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS .� ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3 " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: C� ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER . r ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) ®SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: U to 35' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ❑OTHER: APPROX.BORING DEPTH p CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) COMMENTS::3 soil hormnC iin to tirRt P.nr:olintP.red orminflwAlPr for soil And orotinrlwAlPr rnntlrmation 4amnIPS NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California Laws. SignedTitle/Company Project Scientist/Stantec Consulting Corp. Print Name Bryan Rorie Date February 19, 2010 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: G r WORK PLAN DATED: Z 79 O OK = Z"I 7�I O APPLICATION ACCEPTED BY DATE ISSUED Z12&10 AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO All REMITTED HECK# RECV'D BY DAT PERMIT/SERVICE# INVOICE It= ell- • 21i SR#QJ? ,0 C-57 WC V -WAIVER C57 LETTER-OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 11/5/07(WEB) � IT APP