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?, SAN JOAQUIN OUNTY <br /> , <br /> 2M L- ENI;, �ONMENTAI_ HEALTH DEPARTIVt� JT SITE <br /> {' -�l <br /> �• �� 600 East Main Street, Stockt n, CA 95202-3029 MITIGATION <br /> ___^>3 Telephone: (209)468-3449 Fax: (209)46 -3433 Web:www.sigov.org/ehd UNIT IV <br /> ! <br /> t, r <br /> WELL PERMIT AP13LICATION <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 insta I 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. I f'? 07 <br /> Assessor's <br /> WellLocation2417 West Lane Cross Street Klinger Road . City Stockton Zip 95205 Parcel# 117-09 !y <br /> Property <br /> owner Joseph Rokoszewski Address 2 417 West Lane City Stockton zip 95205 Phone# 916--729-176 <br /> C-57 Contractor WRM Address Box 8 93 8 City CitrLrs Heights Lic#'888763 Phone 916-72 9-x.76 0 <br /> Consultant/Sub Cntr WRM Address Box 8938 City Citrus Heights 'Lic# 888763 Phone 916-72 9-176 0 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ® NEW WELLIBORING(CPT,GECPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (CHOOSE TYPE BELOW) <br /> ® SOIL.BORING# 1 BOrinas ❑ OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Soil Boring to 70 , and collect soil .and ground water samples <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ® HOLLOW STEM DIA.OF BOREHOLE 8 II ❑MULTIPLE CASINGS,©MULTI-LEVEL WELL CASING DIA: <br /> ©EXTRACTION ❑AIR HAMMER/DRIVEN CASING TH{CKNESS TYPE OF CASING:❑STEEL ©PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑ HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED ®Yes ❑No (NOTE: <br /> MAXIMUM FREE-FALL DEPTH 15 301) <br /> ®SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS... <br /> []OTHER: ❑OTHER: APPROX.BORING CEP-H _ 70 Feet El BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING PRO OSED (ii 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 /> hereby certify that I have prepared this application and that the work will be done I accordance with San Jl aquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed �.... <br /> `-,,­ -Title/Comp ny Senior GeolocfiSt/WRM <br /> Print Name Thomas E . Balla-rd Date April 13 , 2009 <br /> I <br /> DEPARTMENT U E,ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:, '1 -7 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY — — [DATE ISSUED � �� � � AREA <br /> GROUT INSPECTION BY j � r FINAL. INSPECTION BY �� DATE / <br /> ! 1 (I <br /> DESTRUCTION INSPECTIC)N BY ,J DAT <br /> COiMMENT ICONDiTIONS: v' <br /> U <br /> ACCOUNTING ONLY: AID# FAC# f <br /> PE CODES FEE INFO AMT REMITTED it RE V'D BY DATE PERMIT/SERVICE# INVOICE <br /> I <br /> 3 Spa 3I �-{0 D l�r 4 '-� !k//42 S R# 0 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHOR ZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) - WELL PERMIT APP <br />