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OZSan Joaquin County G L� F Vii'. ji �Ul <br /> Environmental Health Department SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 11A1� 0 2 2009MITIGATION <br /> •` (209)468-3449 Fax.(209)468-3433 Web.www.sjgov.org/ehd, <br /> Vi�;G'Ni,iir: HEAJFPNIT IV <br /> Well Permit Application PES M1,T;SERVICf'- <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct aodfor 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 Health Department. <br /> Assesso <br /> WELL Location Roth Road Cross Street Harlan ciiyFrench Camglp95231 par 93330280 <br /> P .ene <br /> Eto Property LIAgdress4080 Seaport Blvd cit?. 9_�6$, o (916) 677-0818 <br /> Ownerne <br /> ,,p <br /> C-57 Contractor)ll Yl L Address U cfty6/f G Zip�ic# Phone#OI t(O fq t r[IUD <br /> Consultant t Sub Cntr Address City LIc# Phone# <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED: " <br /> p NEW WELL/BORING (CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> a WELL# D PRESSURE GROUT <br /> 0*Other ELD Testtrig GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA _ <br /> Q EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING, I]STEEL p PVC Q OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS li HOSE <br /> U AIR SPARGE/OZONE a PUSH POINT(GP or CPI)GROUT SEAL PUMPED D Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING a HAND AUGER GROUT_SPECIFICATIONS <br /> >0O .EJ <br /> Q OTHER: RVGLCC��� APPROX.BORING DEPTH g BOLTED TRAFFIC BOX or Q STOVE PIPE i <br /> CONDUCTOR CASING-PROPOSED (if YES,list specifications in comment section) I <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby ce at i have prepared thlb application and that the work will be done In accordance with San Joaquin <br /> County. nan ,R s an gulatio s,and all applicable California State Laws. <br /> signedx Title/Company . Operations Manager-Ramos Oil <br /> Print Name Douglas Hawkins Date 7- t c) <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> � /J n <br /> Application Accepted By C `� 4 I � Date Issued Zl\ l(. n Area <br /> Grout Inspection By. Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> �,Cf, U c> �;� Gr. � 2� �� SR# t70St� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit,Encroachment doc_ <br /> EM 29-02-W1web _ <br /> 6122/04 <br />