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raac r.uuc/uua r-luu <br /> STANISLAUS COUNTY DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> _J 3800 CORNUCOPIA WAY, SUITE C, MODESTO, CA 95358 <br /> J _ (209) 525-6700 <br /> Application For Monitoring Well Construction Permit <br /> (This Pewit Emim I Year FromDaw Issued) <br /> ApprtmtPon L hereby made to the Stanbleus County Department of Environmental Resources for a permit to conduct thowork <br /> herein described. Please notiry dw Hazardous Materials Division at least 49 hours In advance orstartial the work <br /> FACII.ITX/SITE NAME A G p/6 Sid <br /> JOB ADDRESS/LOCATION fli9htvru� . ?3 lax(ay 2aaa� <br /> _I CITY/STATFJZIP 4 5337 <br /> J "WNER'SNAME I'ilt emb, DVi- ADDRESS /9),1? G1 tr <br /> CITY/STATE/ZIP �h ek�m. (4T 9S,)d5 PHONE V 2-G/d l- <br /> 1 DR1I LING CONTRACTORkeRQdrt'Son FG /alt--ajL-"t-57 LICENSE NO 80 a 33 - <br /> J WORKMAN'S COMP H .nn .la4t�von�sir//�/5 5/D� CONTRACTOR PHONE 53b -(ab 3-Z 112-0 <br /> If ceasmrcton of the well(s)willfollow methodoloV described m a work plan on file with the Department of5neiraumental Resoiaces. <br /> please list the title of the work plan,masultait,and dale - <br /> TYPE OF WORK(Cheek): INTENDED USE OF NEW (Cheek): <br /> ❑ Install New Well 0 Groundwater Monitoring/Sampling <br /> Number ofNew Wells 0 Groundwater Extraction <br /> ❑ Install Temporary Well(ar_Hydropunch) 0 Fluid Injection <br /> Number of TemporaryWells ❑ Other <br /> O Well Destruction <br /> 1 Number of Wells To Destroy METHOD OF DRILLING(Check): <br /> J Other Information l D U/ ❑ Hollow Stem Auger <br /> pyuqn <br /> t Other riram g <br /> CONS�RUM'N? ECFCATIO05f <br /> BoringDmter i <br /> DISTANCE TO NEAREST: <br /> Casing Type,Diameter,and Gauge Domestic Supply Well <br /> Expected Depth To Groundwater _ Sewer Imes 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 /> Depth of Filter Pack 11 <br /> Type/Size of Filter Pack Material DESTRUCTION OF st//Ba <br /> and Slot Size. �iameta los/B n7amr din Soy/�a�i�4 <br /> Depth and Type of Transitional cal � WeH Depth U I- 9n i <br /> Depth and Type of Grout Seal ! (Please smch description of mateiaVso1u=c <br /> be used) <br /> G40 I/nP�1 2V QD3- SV-D d Dr& /91 7lwZ 4�9 Trans r 7 2 <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 TAE STATE OF CALIFORNIA,THE ORDINANCES OF THE <br /> COUNTY OF STANISIAUS,AND THE RULES AND REGULATIONS OF THE STANISLAUS COUNTY DEPARTMENT OF <br /> 1 ENVIRONMENT RESOURC <br /> I SIM D ��/ Date: �&7142 <br /> Owner or Authorized Representative) <br /> 0 Permit Usued By: ❑ Permit Deuced By: <br /> PERMIT NUMBER n10 - Date: <br /> DATE ISSUED: <br /> Inspected By: A <br /> Fee Paid: Yes_No� mount <br /> Date: , .,. <br /> ••••,,.,.,..., nim . ncctrF <br />