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Date <br />Date <br />ORIGINAL <br />San Joaquin County <br />OLD Environmental Health Departmentutigy SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 "MITIGATION ) (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orp,epta 2007 UNIT IV <br />Well Permit Application ENVIRONMENT HEALTH <br />Ave city Lodi zip 95242 WELL Location 14749 Thornton Road Cross Street Capitol <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSFDMIT/SER VICES <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 />AssessorsA 5.6/6ozto <br />Parcel# U <br />Ft) 15CY 1.63‘ <br />Address <br />__________ <br />3-494,erntFia Owner el <br />Cascade Cascade Drilling, Inc Sacramento <br />C-57 Contractor Address 3632 Omec Circle City Zip95742 <br />Consultant/Sub Cntr AGE Address 837 Shaw Road CityStockton Lio#680227 Phone# (209)467-1006 <br />GIS Coordinates: X I q <br />WORK TO BE PERFORMED: <br />2ff NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />['SOIL BORING # a OVER-BORE. DIAMETER <br />COMMENTS: SEL- EH..0 A ,o,M ovc.,9 Rc,p;',4 1-- tA)90: P1/9 Ni (iey -rQ c7/51) <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1 /0 <br />El MONITORING 141OLLOW STEM DIA. OF BOREHOLE S I° 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _AlAr <br />I] EXTRACTION a AIR HAMMER/DRIVEN .a•-)e. CASING THICKNESS ,-/ 0 TYPE OF CASING: 0 STEEL .GC ['OTHER: <br />DEPTH OF GROUT SEAL IC " TREMIE TYPE TO BE USED: .-AUGERS a HOSE g VAPOR 0 MUD ROTARY <br />O PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes ..„tk•610 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O HAND AUGER GROUT SPECIFICATIONS Pc.,r TifanD -nip c "•- <br />O OTHER APPROX. BORING DEPTH 25 --11\150LTED TRAFFIC BOX or 0 STOVE PIPE ' <br />CONDUCTOR CASING PROPOSED Ail--) (if YES, list specifications in comment section) <br />FND — 1)seein ir',1 le I---k1 a 4a 091/ 7 (0 7 <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 in accordance with San Joaquin <br />County Ordinan I and $egulations, and all applicable California State Laws. <br />C ity Zip C":90 imkt Phone# <br />Lic# 7/7-5/0Phone# (916)638-1169 <br />—121- 595 , Township Range Section <br />XWELL# Vui .9 1 V1w 5 ,VW -(0 /4w.3 -r4 0 ADV -1? 0 PRESSURE GROUT <br />1 U *Other GROUT SPECIFICATIONS <br />a AIR SPARGE/ OZONE <br />O SOIL BORING <br />['OTHER: <br />COMMENTS: S <br />Signed x <br />Print Name Robert E. Marty <br />Title/CompanyVice President/AGE <br />Date 21 September 2007 <br />NoAi2/60 DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ii/711?-- <br />WORK PLAN DATED: 31 •—lat 07 RAP <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE MIT /_S„.. arP Piliali Sl_..:_tt <br />SI% 2.012_ eth 1 sRve95ziv..? '..) <br />C-57_/ WC -WAIVER /4 C-57 Letter of Authorization to sign permit <br />• • <br />EHD 29-02-001 <br />6/22/04 <br />Final Inspection By <br />Date Issued 4`4/Z7 .5 7777) Area 66 <br />Date f,