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U. San Joaquin County <br /> Environmental Health <br /> Dep <br /> 304 East Weber Avenue,3rd FlooStockton, <br /> rt Cm 9502 0 C 1 1 6 ZO SITE <br /> (209)468-3449 Fax: (209)468-3433 Web: www,sjgov.or <br /> MITIGATION <br /> �*RONMENT HEALTUNIT IV <br /> Well Permit Application PERMIT/SERV <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 /> GaVNT`( CoVATH0VSp, <br /> WELL Location 7-1t E,.W f g It R A V E Ny I- Cross Street Tc y Assessors <br /> — �LilL ARgI Cit s'tackTo�1 zip 9524 Parcel# / 9lG o o � <br /> PROPERTYSANJo QV04 00VNtY STRFFT <br /> Owner CILIT S t Address 111 E. 5to S U <br /> VMI-/a"07 GREGG city ST9C� (CTQ1� Zip9��'10 Phone# <br /> 4SQ�, oaac fZa( , .Cz - ��)46$-965 <br /> C-57 Contractor +F�-�L D(CILLI Address_ _ - 3 5G Sr09 <br /> city zip�Zic hone#l <br /> Consultant/Sub Cntr AMAX 6NY.� It�G 6� s' MEADOW; PKWY <br /> Address 'vl CityI�Cr_5��` S <br /> GIS Coordinates:X .Phone# (-�)$5(- 139 <br /> WORK TO BE PERFORMED- Y ,Township-_ <br /> Range Section <br /> M NEW WELL/BORING (CPT,GEOPROBE,HYDRO <br /> L[D-FIro •) D DESTRUCTION <br /> I SOIL BORING# -4 - (choose type below) <br /> Q WELL# 0 OVER-BORE. DIAMETER <br /> D`Other D PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING E HOLLOW STEM DIA.OF BOREHOLE Q!11 D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_NA__ <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS N A TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS N I A T C t K N <br /> D OTHER: D OTHER APPROX.BORING DEPTH 15-35' D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS:_ RAMAfr•t ENV, 91EVIS�V WORK ALAN ('314106) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces, Rules and Regulations,and all applicable California State Laws. <br /> Signed Title/Company PRE51bEr1T/kAM�kCr� ENV(RoIVMET.JItIING, <br /> Print Name 105L A M A l- Date IU 11-310 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2 2 2 E 4 si- V1(ebe►- AYct3 I_i a <br /> WORK PLAN DATED:_._.. .._ IJd o S t- -4, .2 60 re <br /> Application Accepted ByDate Issued f Area 1 4s <br /> Grout Inspection By ` Date 1-1 3 -D7 Final Inspection By ` Date 0'7 <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: All?# FAC# <br /> PE CODES ZEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> a3 485 '7+ SR# QD SSG <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />