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SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:wwwsiaov.orD/ehd UNIT IV <br /> �dt�":tfl:.RNi <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 /> 95242 Assessors 011-090-14 <br /> Well Location-16667 Jacob Brack Rd. Cross Street Turner Rd. _ City _Lodi _Zip _ _ Parcel# <br /> Property P.O. Box 249 94574 <br /> Owner_Sutter Home Winery _ Address _ City_St. Helena _ Zip_ _Phone#_707-963-3104 <br /> C-57 Contractor Precision Sampling Address _2365 Wigwam _ City_Stockton Lic# 512268 Phono_.209-465-8712 <br /> Consultant/Sub CrYuKennedy/JenKS Address_303 Second St.Ste 300 South City San Francisco Lic# Phone_415-243-2150 <br /> GIS Coordinates:X 6299422 ,Y _2244495 ,Township T4N Range_5E _Section _34 <br /> NORK TO BE PERFORMED: <br /> 12 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑301L BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# GW-7 through GW-12 ❑PRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> RI MONITORING fIOLLOW STEM DIA.OF BOREHOLE 7-Inch 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:2-Inch <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS—SCH 40 TYPE OF CASING:0 STEEL M PVC 0 OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL _4 ft _TREMIE TYPE TO BE USED❑AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:0 Yes M No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat _ <br /> ❑OTHER: 0 OTHER: _ APPROX.BORING DEPTH 20 ft/ _ M BOLTED TRAFFIC BOX OR [3 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (lf YES,list spedfio ons in c n rt seNa) <br /> COMMENTS: Six shallow monitoring wells. <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatfons,a II ap 'cable Calif a Lar- <br /> Signed <br /> a��v{{{sss � ,,f/ a <br /> Si9ned ` Title/Company &A:z <br /> Print Name r'(r Cha Date 7 <br /> �7 �T <br /> DEPARTMENT USEONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /Q 6 / 7 Al• �(t-t_S(� I�r(&z k -,li <br /> WORK PLAN DATED: (f -LVCq Cv&-v-@ e-� <br /> APPLICATION ACCEPTED EIY�J DATE ISSUED 69411l AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 01 <br /> DESTRUCTION INSPECTION BY DATE }. <br /> COMMENTS/CONDITIONS:tA.tt. Tamale, ` <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE PERMITISERVICE# INVOICE <br /> S11#60.767[ <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/907(WEB) WELL PERMIT APP <br />