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SAN JOAQUIN COUNTY <br /> Q'i, ENVIRONMENTAL HEALTH DEPARTMENTSITE <br /> y' E V E MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> a Telephone: (209)468-3449 Fax.(209)468-3433 Web:www.sigov.org/ehd <br /> UNIT IV <br /> a dlAif 12 2010 <br /> ENVIRONMENTHEA►,�{ WELL PERMIT APPLICATION <br /> PEfjMIt/MVrEQ 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 /> Assessor's <br /> Well Location-18667 Jacob Brack Rd._ Cross Street Turner Rd. _ City _Lodi Zip _95242 _ Parcel#_011-090-23 <br /> Property Sutter Home Wine P.O. Box 249 94574 <br /> Owner_ Winery _ Address Ciry_St. Helena _ Zip_ -Phone#_707-963-3104 , <br /> C-57 Contractor Precision Sampling Address _2365 Wigwam _ City_Stockton LIC# 636387 Phono 209-465-8712 _ <br /> Consultant/Sub Cntr Kennedy/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 /> 'N")RK TO BE PERFORMED: <br /> :9 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# GW1 [I PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING C4 HOLLOW STEM DIA.OF BOREHOLE 7-Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:2-Inch <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS—.SCH 40 TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL .4 ft _TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ®IJo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Neat _ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH _20 ft. M MOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSE) (If YES.Ilst s etl5mtlons in mmmwt sec ) <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 t have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,aaapppHHH ap ab California Callif/ornia Laws. <br /> Signed _ ii'C b 41-17 Title/Company Eb <br /> Print Name _Mike McLeod Date <br /> IFI-99 <br /> p �7 AZ DEPARTMENT USE ONLY <br /> p�� <br /> SITE MAP IN UNIT IV FILE,AD RIESS: [l� (9 Qoz <br /> WORK PLAN DATED: // /I D / 61 <br /> APPLICATION ACCEPTED Y DATE ISSUED Z- D AREA''9��44//..9,�..��77.// <br /> GROUT INSPECTION BY — FINAL INSPECTION BY DATjft �10 <br /> DESTRUCTION INSPECTION BY DATE 1 _l• <br /> COMMENTS/CONDITIONS: t ( �M. w / eV? <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> cib( jjq- n - <br /> 111 t IO SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHM NT DOC <br /> EHD 2941 1115107(WEB) WELL PERMIT APP <br />