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S.01 FILE COPY <br /> SAN .10AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> F Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OW • �D3 <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 /> 401 E. French Cam F Ash Road French Cam 95231 Assessor's 19314013 <br /> Well Location P Cross Street City P Zip Parcel# <br /> Property <br /> owner PG&E Address 3401 Crow Canyon Rd city San Ramon Zip 94583 Phone# 925-415-6381 <br /> C-57 contractor ECA Address 3011 Twin Palms Dr. city Aptos Lic# 695970hone 8316628178 <br /> ConsultanVSub Cntr Stantec COnSUlti Address 3017 Kilgore Road Suite 1C�tity Rancho Cordo4l# Phone 9168610400 <br /> GIS Coordinates:x 37.881 y -121.267 Township 715 Range RGE Section 14 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT.GEOPROSE.HYDROPUNCH,HAND-AUGER,OTHER') ®DESTRUCTION(CHOOSE TYPE BELOW) <br /> [ISOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> [:1'OTHER cc// / GROUT SPECIFICATIONS <br /> COMMENTS: JC?- 3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS QN <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3 n ❑MULTIPLE CASINGS M MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS 1/4" TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> M VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 5& 12 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE M PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH 1S 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS IJ �• <br /> ❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed ��� '�- + t{ /� Title/Company Stantec Consulting Corporation <br /> Print Name Bryan Rorie Date 12/2/09 (, <br /> DEPARTMENT USE ONLY60 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: -611T f <br /> APPLICATION ACCEPTED BY _V-dDATE ISSUED 4/-13 110 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED ] CH;ECK# RECV D BY DATE PERMITtSERVICE# INVOICE <br /> C-57 WC -WAIVER ETTEIR OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5107(WEB) WELL PERMIT APP <br /> I r. C 3 POW,y <br /> u <br />