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r <br />C— <br />c7 <br />ean Joaquin County <br />Environmental Health Department rE IT--:, SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9 CE,f1VgiVIITIGATION <br />(209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.orgYhd UNIT IV <br />Well Permit Application DEC 1 7 2007 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE istiffpy RONMENT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describecDPIWriiciiiiiKgiale in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environment-al Health Department. <br />/lipid) e c Assessors <br />WELL Location ;23 0 11) , t../E S7 rvZ._ Cross Street vs/C5I i-44 t City SToc.i; 1% /1 Zip ci 5 g ci`I Parcel* I/ 1 - (35 c.--/? <br />PROPERTY <br />Owner J..A at.- D/3/1:9',/- Address 52;cl fj , WE .S1 LI)IsIE City s m c l< Ton Zip 95 1-04 Phonelk t e0 99,2 -76 3ti <br />C-57 Contractor GR£%.),3 0 f jii .nc) Address 9 5 " 1-4),,, "i:... 124 , City mar." Z-Zip 4 V551 Licit 1.5 (,1-' -Aone# 0 i -0 93 -5-5 to <br />Consultant/Sub Cntr Advanced GeoEnvironmental Address R "I 7 Shaw Ra city Stockton Licit 680227 Phone* (209)467 -1006 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />g NEW WELL / BORING (CPF)GEOPROBE, HY_IOROPUNCH, HAND-AUGER,_OTHER1 g DESTRUCTION (choose type below) <br />IISOIL BORING # 4:1,; 0-...c) f- 1 7 II OVER-BORE. DIAMETER <br />a WELL # 1:1 PRESSURE GROUT a *Other GROUT SPECIFICATIONS <br />COMMENTS: S'a W44cK -Pi/32.4 A -u_o b4Arrer Zoo -7 dtt-rE0 % <br />TYPE OF WELL <br /> <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING <br /> <br />HOLLOW STEM DIA. OF BOREHOLE 2- 1:1 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: OM <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL a PVC a OTHER: - <br />I] VAPOR a MUD ROTARY _ DEPTH OF GROUT SEAL '-: 75 ;.- :. t. -1- TREMIE TYPE TO BE USED: a AUGERS 41-10SE <br />[I AIR SPARGE/ OZONE-AZUSH POINT (GP or(CPT)GROUT SEAL PUMPED: ANYes a No (NOTE: MAXIMUM FREE-FALL DEPTH is 30') <br />*SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pc., r -1-iii..,D Tip E. <br />0 OTHER: g OTHER APPROX. BORING DEPTH 75'' El BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED 'VA (if YES, list specifications in comment section) <br />COMMENTS: -5- I.. FM D -- Afriio ,o1 k 1-kr / dii-T Eil Li Cc-1- a 30 r Z' ., 7 <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x 761 Title/Company S•i P et.r <br />‘d) Q s) ELLA4 Date /1-/ 7/ 0 7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 8230 N . We-si-- Lane. <br />WORK PLAN DATED: +- .20 .200 '7 anrk r r A-0 <br />ORIGINAL <br />Print Name I I'm , r <br />Application Accepted By <br /> v <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br />C eZt.r 4-11 <br />Date .2 <br />Date <br />Date Issued 11 -18 -0 7 Area /455 <br />Final Inspection By Ja c'iltr 14 ni‘e...0214.1 Date 2/ 4/ oe <br />Ad 0 1,1.4 /0,./ P - 4'11) v k P - 1 '1 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY VOICE DATE PE; , ' - ' "e - <br />3 So 1 M <br />3 5 0 3 <br />i„. oo <br />.2.-c4.00 <br />44 3 <br />8 3 • Op ZG 7Y, '&e-1/7 /2 -/g • SR# 1"" e2 i't ..._ 0 04 2 7 7 n <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />EHD 29-02-001 <br />6/22/04