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San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a pennit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Hea1Ur®epartment. <br /> Assessors <br /> WELL Location145 South Sutter St Cross Street Washington City Stockton Zip 9520$ _parcel#149-15-024 <br /> PROPERLY L �J <br /> owner �1"F-( 0{ S�VC/t�— Address 12S 1U' E) bo redo Cltystockton pi,95202 phone# Zo9-93'�--83 <br /> C57 ContractorWeet Hazmat AddressRancho 3195 Luyung Dr CityZip95742Lic#81g548Phmeff 6)638-5564 <br /> 1340 Treat Blvd Walnua2739 (925)948-2655 <br /> Consultant/Sub CntrWes ton Solutions AddressSuite 210 CityCreek IjI4 52Phone# <br /> GIS Coordinates:X 4201823 Y 650633 UTM10S ,Township Dl North Range f Saet Section 20 L <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH AN ) 11 TRUC ON (choose type below) <br /> 0 SOIL BORING# R-BO DIAMETER TT3 <br /> 0 WELL# KF E GROUT <br /> O'Other UT SPECIFICATIONS 1 1 <br /> COMMENTS: eSSucG C 2I - - ;d QxWciri ll,�OC SJKgr'dU� <br /> TYPE OF WELL INSTALLATION TYPE CTIIDN SP FICA S <br /> MONITORING 0 H LLOW STEM DIA.OF RE LU�TIRLE CASINGS ()MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION Q Al HAMMER/D IV N CASING T 1 S _TYPE OF CASING: II STEEL U PVC 0 OTHER: <br /> 17 VAPOR O MU ROTARY DEPTH OF RV TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE []PUS POIN (GP or CPT)GROUT S L IFUMP b Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING II HAND UG R GRDAJTSP GItICATII S <br /> l]OTHER: R OTHER APPROX. RING DEPTH n BOLTED TRAFFIC BOX w n STOVE PIPE <br /> dONDU okr-ASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: 4N <br /> IF r <br /> NOTE: 9FFSITE BORI S REQLARE AtCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 RKING HO NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 herebvlrxrtity the�have pare _WISappucautltq and that the work will be done in accordance with San Joaquin <br /> County__Il Zinancesd R lations,and all�plicable California State Laws. <br /> Signed x.�= Title/Company Project Manager, Weston Solutions, Inc, <br /> Print Name-Tholitnas Fortn Dale June 2, 2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IM UNIT IV FILE,/4DDRESS: I y t S IA77 --f, 5 +_ <br /> WORK PLAN DATED: <br /> Application Accepted By_LhaA6nry Date Issued 6 A/O Fr- Area <br /> Grout lnspeclionhBy Date Final Inspection By Date <br /> Destructbn Inapeo"By Date <br /> COMMENTS/CON dI;7Qy8`: <br /> ACCOUNTING ONLY: AID# FAgI <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35`0Z <br /> SR# SL{ tf <br /> C-57_:= WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> Em 29-0Loo1 WEB <br /> 9/11/2007 <br />