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Zan Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />SITE <br />AVIITIGATION <br />\,\J 1E, 11___J UNIT IV <br />APR c,?, <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 'applicatipti it.„M.1* in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmer,2ta!Malth DepapmA.M. <br />WELL Location ra- C CC 5, At Ft Pc RT iNiA <br />PROPERTY <br />Owner 5- 11 Cis ION /4111PCNT Address S000 S.: A IR PC RT W city 5 tOC(NTON zip 9520C Phone# (Z09) 41 613 -4700 <br />950 ft OWt k D. city MAKIINEZzip 94SS3 Lic#485165Pnone# (91S) 31-'cc,C-57 Contractor (i-RECr-ki. K I Li 04 Cr Address <br />Consultant / Sub Cntr AC-E. E NV C, Address tibS 5,11 tit bOviSP City RNb. Lialt it6. 58 5 L phone# Cti-c) Vs 1-11 39 <br />V <br />GIS Coordinates: X , Y , Township Range Section <br />e 9 Lcha•-- —I Li• 14) <br />IWELL#1444-1,MW-g i lAW -‘J I MV4-1, <br />II *Other c r - 1 <br />COMMENTS: 5 MoNitoKIN6- INT-(..t.c AND (FT LOCATIth <br />" ' Assessors , <br />Cross Street Li I /lC ht City STOCIN tO N Zip 9524 G. Parcel# <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />fl SOIL BORING # a OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,-, u I MONITORING I HOLLOW STEM DIA. OF BOREHOLE i h a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: L. <br />1:1 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S-E H tt C TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ; ru 1 TREMIE TYPE TO BE USED: I AUGERS g HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: I Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N AT CM MT <br />a OTHER: a OTHER APPROX. BORING DEPTH (I o 1 I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED. kIC (if YES, list specifications in comment section) <br />COMMENTS: RAMAG-F- 4 k EVIS -1) WC RK PLAN .' okmp -Livi- (0 4 <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 Ordinapeçs, Rules and egulations, and all applicable California State Laws. <br />Signed x <br /> <br />Title/Company RAMING-t t.Nv MI) 141,MNIA1.1 C, <br /> <br />Print Name s k/M/\C 11 c <br /> <br />Date 4125101- <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Soo., 5 • 4-weirrIA-- <br />WORK PLAN DATED: A <br />Date Issued 4 <br />Grout Inspection By Datet.5 cyt it ) Final Inspection By <br />Destruction Inspection By Date <br />Application Accepted By Area 16 <br /> Date 4, / I / /- <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P SERVICE REQUEST # INVOICE <br />FS-0 I ii• Irci 4,0 2.. 2. S' 6 Al c-//3 it, 7 sR/th 6 0 q 0 ---------„\ <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permi croachment doc <br /> <br />El-ID 29-02-00Iweb <br />6/22/04