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San Joaquin County <br />Environmental Health Department SITE <br />600 E. Main Street, Stockton, CA 95202-3029 111 1 ariMITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.oratebd HEALTPNIT 11/ moIRONMENT <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 />Assessors WELL Location 1001 ()SEMITE, AVE. Cross Street RAILOW Av E. City M A NT ECA Zip 9533 Parcel* 2.Z3 9 C C <br />PROPER'''`k • _ <br />Owner: .1-) Aro1/4- Tio-T Address (ko °1.ts TeSrtit.C...4\,)0LUttt (1144.1elr.C.Zip 11451:6 Phone* <br />v ro <br />GIS Coordinates: X Y Range Section <br /> <br />, Township <br />WORK TO BE PERFORMED: <br />fl NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />fl SOIL BORING # fl OVER-BORE. DIAMETER <br />WELL # a PRESSURE GROUT <br />I *Other 4 - -2V-3 V -4 , V- , V-6 GROUT SPECIFICATIONS <br />COMMENTS: SOL VMPC1i SAMPLE L0E010145 <br />Oil TO) IYI Palms Cave_ city APA-65 zip_44500,uo#Mfgaphonc:(9/6)417- 4858 C-57 Contractor_ard-rot Pt-SS 0 . L_ 3Address. <br />965 . S .11 Consultant/Sub Cntr RAM4E-E ENV. I S MEADOW NC, Address ?kWY4t20-tS— <br /> City RE-1100,1V Lic# g 6 Phone# (47C) 5'5 1 -1.2 39 954I <br />TYPE OF WELL <br />o MONITORING <br />O EXTRACTION <br />fl VAPOR <br />INSTALLATION TYPE <br />HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />U MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS Pi A TYPE OF CASING: fl STEEL a PVC fl OTHER: <br />DEPTH OF GROUT SEAL S TREMIE TYPE TO BE USED: fl AUGERS a HOSE <br />O AIR SPARGE/ OZONE I PUSH POINT (GP or CPT)GROUT SEAL PUMPED: fl Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />E 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS NEAT C MENT <br />I OTHER: VA P C B fl OTHER APPROX. BORING DEPTH 5 I fl BOLTED TRAFFIC BOX or a STOVE PIPE <br />SAMPLE 00 KiN 6-S CONDUCTOR CASING PROPOSED N 0 (if YES, list specifications in comment section) <br />COMMENTS: SA MkG-E E.NV. L1TE ICRIc pukt4 ?i21 <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 <br />Print Name JOSEPH k A A- 6- E <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /a9/ 6: <br />WORK PLAN DATED: 2 2f-7 <br />Application Accepted By <br /> <br />Date Issued <br /> <br />a1 11/1/(YY Final Inspection <br />Date <br />Grout Inspection By —in/ <br />Destruction Inspection By <br /> <br />Title/Company PR t-SIPENT I Rh Mk64- EliviRoNmENTra,iNc. <br />Date itigiCi <br />AP- /taw <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INIO AMOUNT REMITTED CHECK # REC'D BY DATE PER C UEST # <br />-35°403 Te 9F3 2-L lb 5 CAA <br />INVOICE <br />. <br />60 io -It- sRPC5-z2..6 2_ <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />chment doc <br /> <br />EHD 29-02-00Iweb <br />6/22/04 <br />