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SAN JOAQUIN COUNTY <br />IRONMENTAL HEALTH DEPARTMENT <br />CES' �W= Weber Avenue, 3 Floor, Stockton, CA 95202-2708 <br />(209) 468-3449 • Fax: (209) 468-3433• Web: www.co.san-joaquin.ca.us/ehd <br />SITE <br />MITIGATION <br />UNIT IV <br />a JUN 17 2004 <br />WELL PERMIT APPLICATION FORM <br />ORIGINAL <br />NMENT HEALTH <br />%�ERVIC�VQN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />A oaquin ounty 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 />Assessors <br />WELL Location 1876 C?txltry Club Bl%d. Cross Street NESSia1 City Stoc'-ktcn zip95203 Parcel# 123-191-01 <br />PROPERTY Owner �b . MU Y 33nChez Address 1633 W. t City StOC)CtCY1 zip95203 Phone# 209 941-2197 <br />C-57 Contractor W�6 Dri 11 irg Address P.O. Box 336 CitvFio Vista. zip 94571 Lic# 17 0079 Phone# 707 37 4-4300 <br />Consultant/ Sub Cntr �St)ern Geo EbE;j�ddress 1.386 E_ B=er St C438bodland Lic# 51 857 Phone# 530 668-53M <br />GIS Coordinates: X , Y , Township 1N Range 6E Section 4 <br />WORK TO BE PERFORMED: <br />AID# <br />FAC# <br />EW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />---i0 <br />SOIL BORING <br /># <br />0 OVER -BORE - DIAMETER <br />DATE <br />AWELL # <br />MA 8 to <br />0 PRESSURE GROUT <br />M W <br />0*Other: <br />COMMENTS: <br />Grout Specifications: <br />R# <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFI ATO S��- <br />�MONITORING <br />gHOLLOW STEM <br />DIA. OF BOREHOLE RPT-Au'LTIPLE CASINGS? 0 YES ,KNO WELL CASING DIA: 27, <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL R PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS WAOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 2 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: Neat With 5% bentonite <br />0 OTHER:_G <br />OTHER <br />APPROX. BORING DEPTH 18/4-1 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />Q <br />Q,� <br />CONDUCTOR CASING PROPOSED. no ( if YES, list specifications here): <br />*COMMENTS: u� <br />l� 2,"I --i �8%y <br />�j'GtPs� �s78� - 1 ,G(dti E%/�_ ���PV(�, f��,s��Go�Zl Zig <br />& -----3 <br />A uo l o t 4,t Ne <br />G;,r..e Aa.4 f AO7 - r zo <br />- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Title/Company Project Geolgist, WbStem CSO -1 Lneer'S <br />Date V�1_2 O to 1 <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PE RMI ST # <br />INVOICE <br />/ <br />M W <br />R# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign pert -"' Encroacbta 4doc� - <br />EHD 29-02-001 WELL PERMIT SITE <br />8/27/2003 <br />