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'W ffU• <br /> ,oP `' ...... t_y a 2069 San Joaquin County • FILE COPY <br /> UfVh/IL tT yF Mironmental Health Department SITE <br /> w . , -it I <br /> as Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> iViiT/u A�Y U n <br /> ( 9) -3449 Fax: (209)468-3433 Web: www.sigov.org/ehd 2 6[S UNIT IV <br /> I <br /> - ��rFORN Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q CO 1 o U.) <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 /> oaquiinn,CCaouuq(ty Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> W Location 1600 Durham Ferry Road Hv✓y 33 Trac 95376 Assessors <br /> Cross Street City Y Zip Parcel# <br /> PROPERTY �O4'41. a Address �City <br /> i� Phone#�o9.76�--�ODp <br /> C-57 Contractor RSI Drilling Address 220 N. Eas(Street CityWoodland Zip Lic#802334 Phone# (530)668-2424 <br /> Consultant/Sub Cntr Geological <br /> Technics Inc. Address 1172 Kansas Ave. City Modesto Lic# N/A Phone# (209)522-4119 <br /> GIS Coordinates:X .66 ,Y -124. 32-7- ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> OSOIL BORING# 12 Geoprobes p OVER-BORE. DIAMETER <br /> 0 WELL# g <br /> 0-other U PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: See Workplan dated 09/26/07 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIFATIONS See Workplan dated 09/18/2008 Q <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: 2 d <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYrPE OF CASING: []STEEL 0 PVC U OTHER: <br /> []VAPOR ��`0 MUD ROTARY DEPTH OF GROUT SEAL TbtU C TREMIE TYPE TO BE USED: 0 AUGERS []HOSE <br /> OAIR SPARGE/OZONE 7t PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> X-9-SOIL BORING /a HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: See Workplan dated 09/18/2008 <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> �\ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. \1 <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 Ordinances, ule a Regulations, and all applicable California State Laws. <br /> p t <br /> K <br /> Signed ,,//q'''' ``__ Title/Company \Au -C�'Q,` deh-T <br /> Print Name -\C V\ ` Date <br /> DEPARTMENT USE ONLY ���/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��OU CGt lia. GV'g 3/,0- <br /> WORK PLAN DATED: -If 17 <br /> Application Accepted By Date Issued /� if Q, Are <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# ✓ <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encr�o chment doc <br /> EHD 29-02-001 !oP.s.a9oZsso <br /> 6/22/ FILE COPY ` / <br />