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San Joaquin County G <br /> Environmental Health Department SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 Jij+ 0 �� �C9MITIGATION <br /> (209)468-3449 Fax.(209)468-3433 Web.www.sjgov.org/ehd NIT IV <br /> rAL,�� <br /> ` Well Permit Application Ri10 ;r'S1 R, ��I r"'ff <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor <br /> WELL Location Roth Road Cross Street Harlan CityFrench Camgip95231 parcel# 193330280 <br /> PROPEfenettoProperty L144080 Seaport BlvdW•Sacraamen6o 9_6 (916) 677-0818 <br /> OdressC3Lnon <br /> VKZC-57 Contractor(L-1 k1s, l n L Address � K6ACpq%- <br /> %Li <br /> Phone#q �O 100 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED: "' <br /> B NEW WELL/BORING (CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) B DESTRUCTION (choose type below) <br /> B SOIL BORING# B OVER-BORE. DIAMETER <br /> n WELL# B PRESSURE GROUT <br /> B*Other ELD Testtng GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING B HOLLOW STEM DIA.OF BOREHOLE B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA. <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING B STEEL B PVC BOTHER: <br /> B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS B HOSE <br /> U AIR SPARGE/OZONE B PUSH POINT(GP or CP1)GROUT SEAL PUMPED. B Yes B No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING B HAND AUGER _GROUT SPECIFICATIONS <br /> B OTHER: �OTHEgV APPROX.BORING DEPTH B BOLTED TRAFFIC BOX or B 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 /> 1 hereby cert' at 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County nan ,R s anil Pyegulatiohs,and all applicable California State Laws. <br /> Signed �t`'� Title/Company Operations Manager—Ramos Oil <br /> Print Name Douglas Hawkins Date Z— U`� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 WC -WAIVER_, C-57 Letter of Authorization to sign permit!Encroachment doc_ <br /> MM 29-02-001 web <br /> 6/22f04 <br />