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San Joaquin County <br /> • FILE COPY <br /> Envi onmental Health Department SITE <br /> <' Fast eber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ' CE <br /> 4034-9 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> � \vJ <br /> ell Permit Application <br /> MAY 0 7 2009 <br /> NON-REFU ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r p� nt for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Application is her ( 0+KI-4 <br /> Joaquin Counfybe p1P���+ � 9-111 .3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors 163-230-34 <br /> �IVV�n� UCV S. Fresno Stockton Zi 95206 Parcel# <br /> WELL Location 1245 W. hatter Way Cross Street City P <br /> Geo Corporation/JM 95351 (209)522-3271 <br /> PROPERTY Equipment Addre 819 S.9th Street City Modesto zip_L5151 <br /> E <br /> Owner Woodland 95776 802334 (530)668-2424 <br /> RSI Drilling 220 N East Street City Zip Lic# Phone# <br /> C-57 Contractor A ress (209)522-4119 <br /> Consultant/Sub Cntr <br /> Geological Technics In Address 1172 Kansas Avenue City Modesto Llc# n/a phone# .-- <br /> 3� 936 3DS Township <br /> Range Section_ <br /> GIS Coordinates:X .Y� I. , <br /> WORK TO BE PERFORMED: <br /> �NEW WELL/ BORING (CPT,GEOP BE,HYDROPUNCH,HAND-AUGER,OTHER-) /'ODDEST UCTIRE. DIAMETERse type below) <br /> USOIL BORING# 9 Geo robes Q PRESSURE GROUT <br /> Q WELL# GROUT SPECIFICATIONS _ _ <br /> Q'Other _ A` <br /> COMMENTS: See Work Plan dated 1126109 and addendum letter dated 4/16/09 <br /> TYPE OF WELL INSTALLATION TY E CONSTRUCTION SPECIFICATIONS See Workplan v\ <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_ <br /> O MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:- <br /> CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q EXTRACTION O AIR HAMMER/DR EN TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> Q AIR SPARGE/OZONE n PUSH POINT(G or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> >(tSOIL BORING Q HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH Q <br /> CONDUCTOR CASING PROPOSED if YES,list specifications in comment section) <br /> COMMENTS: See Work Plan dated 1/ 6/09 and addendum letter dated 4116/09 <br /> NOTE: OFFSITE BORING REQUIRE <br /> HOURS CCEICE REQUIRED EOR/NAGREEMNT OR CN ROACHMENT PERMITS. <br /> 48 WO <br /> S. <br /> I hereby certify that I have prepare this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances Rules and Re ons nd all applicable California Statue Laws. II <br /> Title/Company . Pr,a�•L <br /> Signed z <br /> .l Dale 5 <br /> Print N <br /> DEPARTMENT/USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �6 C <br /> WORK PLAN DATED: <br /> Date Issued <br /> Application Accepted By <br /> Date Final Inspection <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 35 , SJ3 8 S .oq SR# p 5 3 I <br /> C-57_ WC—WAIVER_ C-57 Letter of Authorization to sign permit ncroachment�dAci <br /> EHD 29-02-001 <br /> 622/04 <br />