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,o•.�a�1�'•,� SAN JOAQUIN COUNTY LSD ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION 10 Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.orq/ehd UNIT IV F ` ENVIRONMENT HEALTH WELL PERMIT APPLICATION PERMIT/SERVICES NON-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. Assessor's Well Location 27011 S Austin Road Cross Street Burnham Road City Ripon Zip 95366 Parcel# 181-16-7 Propertyy Owner Srocchini Farms,Inc. Address 27011 S.Austin Road City Ripon Zip 95366 Phone# 209-465-8712 C-57 Contractor Precision Sampling,Inc. Address 2365 Wigwam Drive City Stockton Zip 95205 LIC# 636387 Phone Consultant/Sub Cntr Herst&Associates,Inc. Address 4630 South Hwy 94-North Outer Road City Saint Charles,MO LIC# Phone 636-939-9111 GIS Coordinates:X 2147843.08 Y 6365654.56 Township 1N Range 7E Section 35 WORK TO BE PERFORMED: M NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") ❑DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ❑OVER-BORE DIAMETER ®WELL# AMw-29 ❑PRESSURE GROUT ❑*OTHER GROUT SPECIFICATIONS ❑EXPLOSIVES DETONATING CARD COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ®MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 inch ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Sch 80 TYPE OF CASING:❑STEEL ®PVC ❑ OTHER ❑VAPOR MUD ROTARY DEPTH OF GROUT SEAL 0-124 feet TREMIE TYPE TO BE USED❑AUGERS 0 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 6 x 94#Portland Cement&Max 5%Bentonite&100 gal water ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 150 feet ❑BOLTED TRAFFIC BOX OR N STOVE PIPE CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have r 1p redZthispplication and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,and all p I al• L ws, Signed . Title/Company Manager-Remedial Services/Herst&Associates,Inc. Print Name William J.Abernath Date January 6,2010 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: WORK PLAN DATED: APPLICATION ACCEPTED BY DATE ISSUED /-IL-)Q AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTIO Y DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE "I SC( 6 q \I S Lk 3 l4rl_ \� 0 SR#L 2/ y C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 10/28/09 WELL PERMIT APP