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03TII/2010 TAU 14: 25 FAX 2094683433 SdC RED 0002/002 <br /> SAN JOAQOIN COUNTY <br /> 4`=".EVL ENVIRONMENTAL HEALTH DEPARTMENT <br /> I" SITE <br /> p;. 600 East Main Street, Stockton CA 95202-3029 MITIGATION <br /> Tele hone:(209)468-3449 Pax:(2�'9)468-3433 Web:www.sioov orci/ehd <br /> 4 201D A UNIT IV <br /> ENVIRUNMENTHEALTH WELL PERMIT APPLICATION <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andkr 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 /> Well Location 18667 Jacob Brack Rd. :Cross Street 'Tums,Rd. Assessors 011-090-14 <br /> City _Lodi ZIP 85242 _ Parcel N_01 1-090-23 <br /> Property - - ' _ <br /> owner_Sutter Home Winery _ Address P•O.Box 249 city_SLHelena _ 2jp_94574 Phone#_707-963-3104 <br /> C57 Contractor Precision Sampling_ Address _2365 Wigwam city_Stockton Lic#636387 Phone_209-465-8712 _ <br /> ConsultawSub Cntr Kennedy/Jenks Address_303 Second St.Ste 320 South City San Francisco Uc# Phone 415-2432150 <br /> GIS Coordinates:X 6299422 ,Y 2244495 1 <br /> _ ,,ToOpsh)p _T4N Range_5E Section _34 _ <br /> 'NORKTO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER') [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> u COIL BORIINGGI� _ <br /> O'CHER 1 ❑OVER-BORE DIAMETER <br /> TEI- I PRESSURE GROUT <br /> ❑'OTGROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIbN SPECIFICATIONS <br /> ®MONITORING C4 HOLLOW STEM - DIA.OF BOREIH,?LE 7-inCh„ 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA 2-inCh <br /> ❑EXTRACTION O AIR HAMMER/ORIVEN CASING THICKNESS_SCH 40 TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> •VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 4 @ _TREMIE TYPE TO BE USED 0 AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PVMPED:❑Yea IM No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> tD SOIL GORING ❑HANDAUGER GROUT SPECIF!.:AnONS _Neat _ <br /> ❑OTHER. ❑OTHER: 'APPROX.861RIN1.DEPTH _20 R ®IIOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSEC i;:YES,Yst sPedfigliens in mmn,ent saceon) <br /> COMMENTS:Three shallow monitoring wells on Winery parcels. <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 Lie done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulation all applicable Cp*orn)a Layrs. <br /> Signed Title%ompanyw- <br /> i s <br /> Print Name _Mike McLeod Date -3/tc <br /> s <br /> �j/ -1 <br /> DEPARTMENT USE ONIL <br /> SITE MAP IN UNIT IV FILEt ADDR SS: IRR / Al- a"r - �-�� /[ <br /> WORK PLAN DATED: / <br /> 1 <br /> APPLICATION ACCE ° DATE ISSUED La d AREA <br /> GROUT INSPECTIONfiNAL INSPECTION BY DATE�ID - <br /> DESTRUCTION INSPECTION BY SATE <br /> COMMENTS/CONDITIONS: wa�' 7? - <br /> i <br /> ACCOUNTING ONLY: AID It FAC# <br /> PE CODES FEEINFO AMT REMITTED CHECK# RECV'D BY DATE PERMfi/SERVICE# INVOICE <br /> 85- lily 17 310 /0 SR#6 <br /> C-57_WC _ -WAIVER - C57 LETTER OF AU.HORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD2841 1U 07(WEB) WELL PERMIT APP <br /> , i <br />