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oAqul,y FILE <br /> SAN .10AQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT —Cpy_ <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> • coq. P Telephone:(209)468-3454 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 <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 /> Assessors <br /> Well Location 1085 South Union Road Cross Street Wawona Street City Manteca Zip 5337 Parcel#222-240-12 <br /> PropertyCordon Family Trust Owner Address2414 Telegraph Ave. city Zip <br /> Phone#510-548-1485 <br /> Jim Gordon <br /> C-57 Contractor Penecore Address 1238 Alice Street, Suite A City Woodland Zip 95776 Lic# 906899 Phone <br /> Consultant/Sub Cntr ARCADIS Address 1410 Rocky Ridge Dr. City Roseville Lic# Phone 916-786-0320 <br /> p uite 330 <br /> GIS Coordinates:X �]�• o 'Y ,Township 2 South Range 7 East Section 6 <br /> WORK TO BE PERFORMED: <br /> ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER-) ®DESTRUCTION(CHOOSE TYPE BELOW) O <br /> M SOIL BORING#35 surface samples, 13 subsurface samples to 5 feet ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER X GROUT SPECIFICATIONS ree a neat cement gl <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: ' ^ <br /> v_) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> M SOIL BORING M HAND AUGER GROUT SPECIFICATIONS Free-fal I neat cement grout <br /> ❑OTHER: IN OTHER: Direct Push APPROX.BORING DEPTH Max. depth 5' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: Backfill with neat cement grout. <br /> CONDUCTOR CASING PROPOSED (I 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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all aplicable)aiornia Laws. <br /> Signed L. Title/Company <q_�7 S <br /> Print Name t,2 ✓ Date v <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> 7 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY (�,l DATE REA6 <br /> GROUT INSPECTIOI�.i3" — /w V FINAL INSPECTION BY DATE 7-16--Ib <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> o� o� R#©-5?ogz <br /> vg <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ffTMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />