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o San Joaquin County <br /> z Environmental Health Depart SITE <br /> u V ��� <br /> � { 600 East.Main Street, Stockton, CA 95202- <br /> SITE <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov,c��ea 2 08 <br /> Ehd UNIT IV <br /> L 'qw Well Permit Application [[11 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work describe 16 WWW"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 /> Assessors <br /> WELL Location 860 E. Pine Street Cross Street Kelly Street City Lodi Zip 95241 Parcel# 04906013 <br /> PROPERTY <br /> Owner RussellAAK''ishida Address PO Box 2360 City Lodi Zip 95241 Phone# (209)329-6258 <br /> C-57 Contractor A(�Fis�_ Address City_�44<, Zip Lic#6ffdZ27 Phonek`,2,oq�461_—(DO;Io <br /> Consultant/Sub CntrAdvancedGeoEnvironmental Address 837 Shaw Road City Stockton Lick 660227 Phone# (800)511-9300 <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING (CPT,<EOPROBE YDROPUNCH,HAND-AUGER,OTHER-) Il DESTRUCTION (choose type below) <br /> ,SOIL BORING 0-1,P-2,P- 5,P-6 OVER-BORE. DIAMETER <br /> (]WELL# 0 PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA,OF BOREHOLE 1_5 p MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: o STEEL p PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE JLPUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ASOIL BORING aHAND AUGER GROUT SPECIFICATIONS e.tl-t- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 2@6 Oft,401 Oft 0 BOLTED TRAFFIC BOX or Q 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 x7 111LS�lit/V` Title/Company Staff Geologist/AdvancedGeooEnvironmental <br /> Print Name Shawn Agarwal Date 4o` zi? 01? <br /> DEPARTMENTUSEONLY <br /> 96 E <br /> SITE MAP IN UNIT IV FILE ADDRESS: . P,aL.L� /t- . <br /> WORK PLAN DATED' �7�'L/ 10 7_o v�t <br /> Application Accepted By gr6e Date Issued �� .. �+� Area.f?7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: C'VCr% JQ.eaA— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> `113 -- l ?r o� SR#t d05T,82.6 <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 />