Laserfiche WebLink
STANISL.AUS COUNTY DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> ll 3800 CORNUCOPIA WAY, SUITE C, MODESTO, CA 95358 <br /> (209) 52S-6700 <br /> Application For Monitoring Well Construction Permit <br /> (this permit Etryites I Yrs Froin Date Issued) <br /> Application 4 hereby made to the Stanislaus County Department of Environmental Resources for it permh to waduet the= <br /> hemin described. Please notify the Hazardous Materials Divisku at least 48 hours In advance of suiting tbework <br /> FACII ny/Sl•TE NAME S <br /> JOB ADDRESS/LOCATION>L199i � bier h4 l 'I <br /> CITY/STATE1ZIP V n u l t��53-i <br /> OWNER'S NAME A 0 C 0 Lio .'- ADDRESSyb'Ry li9i�f ,9r✓�Ct� ,15 /�i lase <br /> CITY/STATFJZIPda e �Gff .4.5'36/ PHONE .fid9-5lS y537J <br /> 1 DRILLING CONTRACTORAM MO f SmIL N-,yy4 AyJC-57 LICENSE NO 8 e) .3i4 <br /> J WORKMANS COMP 4 ILA 66 51 o2 I D utm D gm ja ran v_CONTRACTOR PHONE 530 -IM-24-'q <br /> If ceawuction of the wells)aril follow methodology described in a walk plan rnt file with the Department ofEnvir moow R=vzc s, <br /> lplease list the title of the work plan,mnailtatR and date <br /> _J 1YPE OF WORK(Check).- INTENDED USE OF NEW WELL(Check): <br /> ❑ Install New Well O Groundwater Monitoring/Sampling <br /> Number ofNew Wells o Groundwater Extraction <br /> ❑ Install Tempporary Well (ex. Hydroptmch) C3 Fluid Injection <br /> Number of Temporary Wells ❑ Other <br /> ❑ Well Destruction <br /> Number of Wells To Destroy METHOD OF DRILLING(Check): <br /> Other Information I sm 11n� a k n D- 1) !a ❑ Hollow Stem Augeef� <br /> -� CAW- Soilae El qrub nntk � Other 6 o3m r_ <br /> CONSTRUCTIOrf SPECIFICaATI01 S• <br /> Boring Diameter (0 5LS u n CkCs SD, l bL?a L�_ DISTANCE TO NEAREST: <br /> Casing Type,Diameter, and Gauge Domestic Supplyq Well <br /> Expected Depth To Groundwater Sewer Lines or Septic Tank/Leach Field <br /> Expected Depth of Well Rock Well or French Drain <br /> 7 Depth of Screened Interval — Other Subsurface Structure <br /> J Depth of Filter Pack <br /> TyWSize of Filter Pack Material DESTRUCTION <br /> and Slot Size. A�a3VeNDiameterj�.. �ek�i! s <br /> Depth and Type of Transitional Seal — "Well Depth <br /> Depth and Type of Grout Seal Full F&_ta — (Please nowlt desuiption of matmiaVeolume cod procedures to <br /> be used) <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 /> JI HEREBY CERTIFY THAT I HAVE PREPARED TWs APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WrW THE PROVISIONS OF TM LAWS OF THE STATE OF CALIFORNIA,THE ORDINANCES OF TBE <br /> _ I COUNTY OF STANISLAUS,AND THE RULES AND REGULATIONS OF THE STANISLAUS COUNTY DEPARTMENT OF <br /> MMMONN09TALRESOURCES / <br /> SIGNED: Date: 6l2�l 3 <br /> Owner or AuthorizedRepresentative) <br /> ❑ Permit Issued By o Permit Denied By: <br /> PERbf[T NUMBER - Date: <br /> DATE ISSUED: <br /> Inspected By: Fee Paid: Yes_No_Amount <br /> Date:-- '•„ <br /> ��,•••*•••n n1W - nCPIrF <br />