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-.,_ian Joaquin County a <br /> V[f�WED� <br /> Environmental Health Depar SITE <br /> IN 304 East Weber Avenue, 3rd Floor, Stockton, CA 9MV 3 n e-UIU MITIGATION <br /> `mss (209)468-3449 Fax: (209)468-3433 Web: www UNIT UNIT IV <br /> C�ll�g YY�l J 1 H <br /> Well Permit Application PERMIT/SERVEC <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. /470 7 <br /> 639 West Clay Street Lincoln Stockton 95206 Assessors //��,La( <br /> WELL Location Cross Street City Zip95206 14707/ () 7 <br /> West Clay Properties <br /> PROPERTY PO Box 6152 Stockton 95206 948-0302 <br /> Owner Address City Zip Phone# <br /> AII Weil an onmen 3809 Pleasant Valey 95667 848359 800-948-1355 <br /> C-57 Contractor Address ity Zip Lic# Phone# <br /> Consultant/Sub Cntr Advanced GeoEnvironmentalAddress P�7 gh— R i City Stockton LIC# E3_( Phone# (209)467-1006 <br /> GIS Coordinates X _.Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> @ NEW WELL/ BORING (CPT.GEOPROBE, HYDROPUNCH. HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BO # 0 OVER-BORE. DIAMETER <br /> ®WELL# VV2;172E7lv� Y,1 8 -q-1 a 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING if HOLLOW STEM DIA.OF BOREHOLE8 inch MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: two- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL lyPVC 0 OTHER: inch <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 40 feet TREMIE TYPE TO BE USED: 16AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') C. <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 75 eet BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> $.o/-1 q -r-h re,0- CONDUCTOR CASING PROPOSED (if YES.list specifications in comment section) <br /> COMMENTS: T/�O monitoring wells installed to assess dissolved contamination <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 Ord;nainces, Rules and Regulations, and all applicable California State Laws. <br /> Signed ��� Title/Company GEOLOGIST/AGE <br /> Print Name WILLIAM LITTLE Date 07/30/01 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 6 3 9 west- ('14- Sfire e t <br /> WORK PLAN DATED: `/ II he b r ua r U 22; c2 6/ 0 Q <br /> Application Accepted�B/y V T �" Date Issued_ 7 3 0 -/ 0 Area <br /> Grout Inspection By r i � I/iG Date B' 9'/e _Final Inspection By 8 ' Z6 '/d y'C}dr 4M" ate �y' 20-16 <br /> Destruction Inspection By Date fjyyf 8 9-/o <br /> COMMENTS/CONDITIONS: -1r1.Sf p l l zi f:rr4n-( M W-2 7 lii2ll/ Al V1 2- A -2- <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �� . 0 6 3 156 / '�/4( -7 3a �D SR# <br /> / 89.oU <br /> 3so3 a�s.co G 00606 92- <br /> C-57- <br /> 2C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> (;177104 <br />