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g4 I" SAN .JOAQUIN COUNTY Idt <br /> 2 s ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> EQ 600 East Main Street, Stockton, CA 95202-3029 R�( TION <br /> "telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd � � <br /> G ZO10 WELL PERMIT APPLICATION JUL 010 <br /> ENVIRONMENT HEALN SAN JOAQUIN COUN <br /> PERMIT/SfRViCE NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMgEE N <br /> HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made Dcompli8} "ilii San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 12745 N Thorn I-5 & Fronto e o Lodi 95242 Assessoes055-130-16 <br /> Well Locationfd Street g C Zip Parcel# <br /> Property <br /> Owner City Of Lodi Address City Zip Phone# <br /> C-Wcontractor Paul Graham Drilling PO Box 669 Rio Vista 94571 787374-512_ <br /> �.ry City zip94571 Za P one <br /> Consultant/Sub Cntr IranilKETlq Address 2625 Fair Oaks Bti(yd Sacrament-;9# 3157$&Gne 916 482-2847 <br /> GIS Coordinates:x 6306185. 0 ,Y 2219583 . 5 Township 3N Range 5E section 2 4 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> J,•OTHER F.P A mons o d waste water injection GROUT SPECIFICATIONS <br /> well ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: EPA permit # 10910003 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 71--lI ! hSMIOULTIPLE CASINGS IPJ MULTI-LEVEL WELL CASING DIA: ' C <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS R55 TYPE OF CASING:Iff-STEEL ❑PVC ❑ OTHER p. <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 9 TREMIE TYPE TO OE USED❑AUGERS❑HOSE �\ <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:00 Yess..1�❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS CA45S G 16 165 0.0 yr)10n f Q <br /> r3:OTHER: Inj ectiou OTHER: APPROX.BORING DEPTH 7 60 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 I W N UCTOR CASING PRgPoSE lif YES,list opeofioabore in no.ert radion) K <br /> COMMENTS: u5 ��A TU 6t (/1'1SIN,I G <br /> 5 <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 I accordance with San Joaquin County Ordinances,Rules and ( <br /> Regulations,a d llapp le alifornia Laws. <br /> Signed �^� _Title/Company Permit Coordinator/Irani Engineering <br /> Print Name Mar Halp n Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED /�hF �Y.CPL SI�-�L� DAT ISSU /Z��V AREA JI' <br /> GROUT INSPECTION BY FINAL INSPECTION B ' DATE( <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CON DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3 3Z ryJ d — 5 3 2`1 W-c— li 3 v SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHM NT DOC <br /> EHD 29-01 1012BI09 WELL PERMIT APP <br />