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14CE VED <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />INSTALLATION TYPE <br />HOLLOW STEM <br />1:1 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />San Joaquin County <br /> <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 OCT 1 6 20061ITIGATION (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgt* RONMENT HEALIUNIT IV <br />Well Permit Application PERMIT/SERVICES <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 />CCVNTY COVIVrii 0 V; E Assessors WELL Location tit E,WEStii AYENYE <br />STREFT <br /> <br />Cross Street 5A ti 1-040.viN City SI 0 C ti10 951 Parcel# 49 IC 00 i <br /> <br />1.4 Zip 02 <br />PROPERTY SAN :TGALI,ViN COV,Nti <br />Owner FACILITLE MG.MT. otpr. Address 1.71/ E. 5 CCM AVE. City STOCktOti Zip 9c105 phone# (2o9)41)E-90.5 vmi-io,o? GRE6-0. cii0 I-1 (nue 121 /rO n-ti n . 2- ,,tielf3 A YA fifiT i,/.30_,v,w44-448,6o 0 C-57 Contractor-NifCittll DRILLINcr Address 19Ce ?V'Ilki u: ME, ” <br /> <br />, City r--1444,-KA Zip S0 , Lic#t-t-tttl—Phone“ <br />Consultant / Sub Cntr E.AMAG-F- ENY•, INC Address S.‘d at L0, p t 51 City t'N Or NV Lic# kG-St S.( Phone# 01- S I -1-239 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROP NCH, HAND-AUGER, T R*) 0 DESTRUCTION (choose type below) I SOIL BORING # 13- 5', <br /> <br />DWELL,* <br />fl *Other <br />COMMENTS: <br />4ç,S Si MEA tithed; PkwY <br />RIGIN 0 OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE ie J. a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: NA <br />CASING THICKNESS N A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />U AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />I SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS NEAT CE ME NI <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 15 -35 1 a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />COMMENTS: SA t•1 !IC,- E ENV, KE.ViStU ‘NClits FLAN (73(410() <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordiaqces, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name JcsH,1.1 ti(1 /441‘c- <br /> Title/Company /RAMAG-E ENviRDNHENTAL4 lwc <br />Date IC 113 6 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />DEPARTMENT USE ONLY <br />22 42 East WeiveA' A'Yenue. <br />WORK PLAN DATED: Augost- 4, 2 OD g <br />Application Accepted By latie/L-gt Date Issued ird t•e y- 1'? 260,6 Area q <br />Grout Inspection By VI Final Inspection By ic,firrIpt, tkaieheeiDate /..13- 07 CA-a r ia L M iZarirtAr7 Date J-/ 3 -07 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: M11411.6erti Oc ; ) 13 -4 e-s-- g- <br />ACCOUNTING ONLY: AID# <br />c., <br />FAC# <br />PE CODES ZEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />30 I 5 <br />35' a 3 <br />49 99 <br />485 f 3'74' R# do4,8 56 1 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit oachme <br /> <br />EHD 29-02-001 <br />6/22/04