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_J 89}v...c'3T4S <br /> STANISLAUS COUNTY DEPARTMENT OF ENVIRONMENTAL RESOa . <br /> CES <br /> 3800 CORNUCOPIA WAY, SUITE C, MODESTO, CA 95358/ , <br /> (209) 525-6700 1 <br /> Application For Monitoring Well Construction �rIngE o o* <br /> s Pemrit B 'res I Year From Date Issued <br /> Application is hereby made to the Stanislaus County Department of Environmental Resources for a pe erubsct the work <br /> herein descnbed. Please notify the Hazardous Materials Division at least 48 hours in advance of starting th yZy� . <br /> LlFACIIdTY/STTE NAME j4,qCnS <br /> JOB ADDRESS/LOCATION Af A l(n-38-t)3 W6:N 33 -b I L A4 <br /> S <br /> CITY/STATE/ZIP VekNAli 5 , c,4 G 3 7- <br /> OWNER'S NAME Rasp I1 n -b r rr f Arc.ns ADDRESS 2624 S,�AIT q„Iw 15.J�21y <br /> CITY/STATE/ZIP L LJA1e , CA 9 GAb I PHONE 20q_595- SSa <br /> DRILLING CONTRACTOR G ( ` C-57 LICENSE NO L/RS/!a5 <br /> i WORKMAN'S COND <br /> Gm A Y�� CONTRACTOR PHONE 9n�-3l3-58�P1 <br /> If construction of the well(s)will follow methodology described in a work plan on file with the Department of Environmental Resources, <br /> please list the title of the work plan,consultant,and date <br /> TYPE OF WORK(Check): INTENDED USE OF NEW WELL(Check): <br /> ❑ Install New Well ❑ Groundwater Monitoring/Sampling <br /> Number of New Wells ❑ Groundwater Extraction <br /> ❑ Install Temporary Well (ex. Hydropunch) ❑ Fluid Injection <br /> Number of Temporary Wells . ❑ Other <br /> o Well Destruction <br /> Number of Wells To Destroy METHOD OF DRILLING(Check): <br /> Other Information /6 y, / fm Sa-r LO p( Hollow Stem Auger—g2 /iio ei . <br /> 6wect Sail aid 64V 6011NA rZ" ❑ Other <br /> CONSTRU ON SPECIFICATIONS• <br /> Boring Diameter US a c1 i n,,n &'d l py�21DISTANCE TO NEAREST: <br /> Casing Type, Diameter, and suge Domestic Supply Well <br /> Expected Depth To Groundwater Sewer Lines or Septic Tank/Leach Field <br /> ' Expected Depth of Well Rock Well or French Drain <br /> Depth of Screened Interval Other Subsurface Structure <br /> Depth of Filter Pack <br /> Type/Size of Filter Pack Material i00 DESTRUCTION OF L.`-D/1 &4`14; <br /> and Slot Size_ �SxISYeHDiameter(n5/ Soil 8t!b/asluboKtnc� <br /> Depth and Type of Transitional Seal ISt illAW Depth Say r S <br /> Depth and Type of Grout Seal OCTIJ (Please attach description ol''material/volume and procedures to <br /> - , be used) <br /> aunub Si U/ah con zAr f a 73 <br /> NOTE: A detailed and scaled site plan with proposed drilling locations, and proposed well construction <br /> diagrams, MUST be attached to this application. <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA,TBE ORDINANCES OF THE <br /> COUNTY OF STANISLAUS,AND THE RULES AND REGULATIONS OF THE STANISLAUS COUNTY DEPARTMENT OF <br /> - <br /> ENVIRONMENALRESOURCES <br /> -� SIGNED: _ Date: <br /> ° 8103 <br /> Owner or Authorized Re resentative n/ r477Ar- <br /> 11 <br /> ❑ Permit Issued By: El Denied By: <br /> PERMIT NUMBER: - Date: <br /> DATE ISSUED`. - <br /> ' Inspected By: Fee Paid: Yes_No`Amount 606 <br /> Date: <br /> 4013-58 WHITE - APPLICANT YELLOW - CONTRACTOR PINK - OFFICE <br /> _l <br />