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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 - <br /> (209) 468-3449 JJ <br /> L 2 6 ZO01 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED li , <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ap�licationis i=rl�c�e In cgmph;nce wdt <br /> San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health S rvicc;j+�nYiranmep at-tH=al;h Owis:er <br /> "Rs'ses �s <br /> WELL Location 1645 Cherokee Lane Cross StreetSanguinetti cit,/Stockton Zip95205 Parcelz 119-100--05 <br /> PROPERTY Owner CA Traction Company Address 2201 W. Washing tonCityStockton Zip 95203 Phonez209-466-6927 <br /> C-57 Contractor Spectrum Exp. Address 2365 Wigwam Drive CttyStocktonZip95205 Llc#512268Phone-0-09-465-8712 <br /> Consultant/Sub Contractor Hydro—Env. Tech. Address 2394 Mariner Sq. 0;tyllameda ti�N/A Phone=510-521-2684 <br /> Suite 2 <br /> GIS Coordinates:X 4204400 mN Y 652400 mE ,Township 2N Range 6E Section 43 <br /> WORK TO BE PERFORMED <br /> (KNEW WELL/BORING(CPT, GEOPROBE,HYOROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below! <br /> 0 SOIL BORING# I]OVER-BORE <br /> ja WELL# MW-4 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [MONITORING Xk1HOLLOW STEM DIA.OF BOREHOLE 8.0" MULTIPLE CASINGS?0 YES (f NO WELL CASING DiA 2.0" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: 0 STEEL R PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 10 ft TREMIE TYPE TO BE USED: 0 AUGERS 't-H;oS= <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: xI Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 50 ft BOLTED TRAFFIC BOX or 0 STOVE PIP: <br /> HAND AUGER APPROX. BORING DEPTH �I <br /> 0 <br /> OTHER:_O OTHER CONDUCTOR CASING PROPOSED? No (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certt i <br /> ify et I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> ' CALL THE !!NIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> C ` t�es{et,s IC.Y r.>,s.11 �1.ir, ✓ 6✓� Jnr .:r r�s,a.,suE Tai:. �C <br /> Signed x <br /> TiUe/Company / <br /> Print Name W,ll,ucti C. Date 2 qLI <br /> LT ILI <br /> SEE SITE MAI' I UNIT IV FILE WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued Z G Area <br /> Application Accepted By b�i Date <br /> Grout Inspection By Date 6 (�JO 1_Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS t CONDITIONS: <br /> EACC.OUNTINIG ONLY: AID# =Ar <br /> FEE INFO AMOUNT REMrrTFD CHECK;; REG'D BY DATE <br /> PERMITISEIRVICEREQUEST# INV�ICc <br /> } z o/ coo a6� t <br /> e l•-�inn <br />