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It <br /> San Joaquin County <br /> ° r U L;I':-" E COPY <br /> Za <br /> Environmental Health Department SITE <br /> " 304 East'Veber Avenue, 3rd Floor, Stockton, CA 9510(2 P — 5 2008 <br /> (209)468-3419 Fax: (209)468-3433 Web: www.sjg MITIGATION <br /> oa< ai M*INVIEN1 HEALIH UNIT IV <br /> e#o <br /> Nell Permit Application PERMIT%SEERVVItC�ESc <br /> NON-REFUN ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6 `£J <br /> Application is hereby made to San Joaquin Counb 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 9-111 i.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1245 W.Charter Way S. Fresno Stockton 95206 Assessors 163-230.34 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY Geo Corporation (209 522-3271 <br /> Owner Addres 819 S.9th Street City Modesto Zip 95351 Phone# ) <br /> C57 Contractor V&W Drilling Add esa P.O. Box 970 City Lodi Zip Lic#720904 Phone# <br /> 95241 (209)369-9600 <br /> Consultant/Sub CntrGeollogical Technics Inc Address 1101 7th Street city Modesto Lip/ n/a phone# (209)522-4119 <br /> GIS Coordinates:X 31.9% ,Y-I .j0 Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPRO 3E,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> Z <br /> SOIL BORING# GP-4&GP-5 a OVER-BORE. DIAMETER WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: See Work Plan dated10/1/ 007 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> II MONITORING II HOLLOW STEM DIA.OF BOREHOLE_ 2,�'U MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVE N CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br /> Q VAPOR JIMUD ROTARY DEPTH OF GROUT SEAL 30' TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> ��`0���•AIR SPARGE/OZON PUSH POINT P or PT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING I) ANDAUGER GROUT SPECIFICATIONS IN� GN� <br /> tl�p OTHER:_g OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See Work Plan dated 10/11 07 <br /> NOTE: OFFSITE BORINGS EQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WOR NG HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepay d this application and that the work will be done in accordance with San Joaquin <br /> County Or linan , R lle d ( gulations, and all <br /> allll applicable California State Laws. <br /> Signed x ____1t •� Title/Company l�e O luT Ca ( �ie[-X1171 C s L' - <br /> Print Name 6am rl 1 6 .X bloc m- Date a I y 1000 <br /> DEPARTMENT USE ONLY /Vnt 2) <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Zi< W <br /> 14 <br /> WORK PLAN DATED: / O <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date '0 Final Inspectiony Date <br /> Destruction Inspection By Date <br /> COMMENTS ICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITT D CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> I 8q c D2olo 5 s715, <br /> R# d53 31-3 <br /> C-57 WC -WAIVER_ C-5 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22104 <br />