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oPAu�N••c . My <br /> �- San Joaqu-in C ' WAYMEN7 <br /> = 2 Environmental Health De RECEIVE <br /> "• Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 SITE(209)468-3449 Fax: 2 JAN 3 0 200f�ITlGATION <br /> ( 09)468-3433 Web; wwws o B <br /> Well Permit Application SANENVVIIRONMENOTAL UNTY UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED HEALTH DEPARTWuL —_ � <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 Develop Tr.74114ap ,9-7175. CityZ3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Locatl.,VPROPERTYs, 9ff-a Cross Street r5 e,- Stockton ip Assessors <br /> Owner FJS Ranches PTP Parcel# <br /> Address 2928 Dwight Way Stockton <br /> V&W Dri l l in4 City_ —Zip phone# 209-463-1456 95204 <br /> C-57 Contractor Address P-0 Box 416 <br /> Isleton <br /> Consultant/Sub Cntr <br /> Kleinf elder Inc <br /> , . City Zip 95641 Ligt720904 phone# 916-777-410o <br /> Address 2825 E. Myrtle St.Cih, Stockton Lic# NA <br /> GIS COordinates:X Y � Phone# 209-9_ 48-1345 <br /> Township—_Range <br /> WORK TO BE PERFORMED: Section <br /> ITNEW WELL/BORING (CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER, <br /> 0 SOIL BORING# OTHER`) 0 DESTRUCTION (choose type below) <br /> ff WELL# 0 OVER-BORE. DIAMETER <br /> 0`Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 5 MONITORING [;HOLLOWSTEM DIA.OF BOREHOLE 8 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_� <br /> 0 EXTRACTION a AIR 0 MUD ROTARY <br /> CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL It•PVC 0 OTHER: <br /> 0 VAPOR DEPTH OF GROUT SEAL PVC <br /> TYPE TO BE USED: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 9AUGERS 0 HOSE <br /> D 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS Neat cement w/4$ Bentonite <br /> 0 OTHER:_U OTHER APPROX.BORING DEPTH 80' Powder <br /> 0 BOLTED TRAFFIC BOX or <br /> CONDUCTOR CASING PROPOSED NA ffSTOVE PIPE <br /> COMMENTS: (if YES,list specifications in comment section) <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company_ 7 i7 <br /> Print Name <br /> DEP RTMENT USE ONLY <br /> it qty <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: y 7 <br /> Application Accepted By / / <br /> Date Issued —t!/'� O` <br /> Grout Inspection By Date Finl IArea V <br /> Inspection By <br /> Destruction Inspection By Dat Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFOEOUMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 9• v� SR# 0 y7-10 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_EncrycE�ment doc <br /> EHD 29-02-001 POA" CZ �'_-'`;���j/C 0".0 <br /> 6122104 �������/ �• <br />