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�oPgy!N,co ,.wan Joaquin County .. <br /> �= z� Environmental Health Depart�COVEDMITIGATION <br /> SITE <br /> < 600 East Main Street, Stockton, CA 95202- <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.q�g/�hd p UNIT IV <br /> U(C v <br /> Well Permit Application © ZOOV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE NMEN T HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. l hA=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 /> Kelly Street <br /> Assessors <br /> 04906018 <br /> WELL Location 860 E. Pine Street Cross Street City Lodi Zip 95241 Parcel#arcel# <br /> PROPERTY <br /> Owner RussellAAK��iis�shida Address PO Box 2360 City Lodi Zip 95241 Phone# (209)329-6258 <br /> C-57 Contractor MnS Address n-7 City -dew Zip Lic#6ffaZZ7 Phone<Z 461(00)0 <br /> Consultant/Sub Cntr AdvancedGeoEnvironmental Address 837 Shaw Road City Stockton LiC# 680227 Phone# (800)511-9300 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE YDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> &SOIL BORING#P-1,P-2,P- _5'P_6 �OVER-BORE. DIAMETER <br /> a WELL# p PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: �- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 1.5 a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> AIR SPARGE/OZONE J&PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �jSOIL BORING a HAND AUGER GROUT SPECIFICATIONS Ce-me-o't- <br /> OTHER: OTHER APPROX.BORING DEPTH 2@6 Oft,4@1 Oft a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 ZA +Ait� � Title/Company Staff Geologistt''/gqAdvanccedGeoEnvironmental Ly <br /> Print Name Shawn Agarwal Date — Zv—01? <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: t%o E . jpx';' C, 1. c�-9' 6o <br /> WORK PLAN DATED: .s Z�-f ,r -7 <br /> Application Accepted By Date Issued ��/ Jl Area <br /> Grout Inspection By .( Date it rox. Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: r V&'t'-)5C- , ,A <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> `1/3 g 3r o�? SR#605_'882_6 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />