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oes ^..� • San Joaquin County • �`\f" <br /> o �� v <br /> Environmental Health Departure SITE <br /> "• + " r=< 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: ww-w.sjgov.org/Q, C00$ UNIT IV <br /> �gCiFORN`P Well Permit Application ENVIrtOMNIE?i? iiEl>''H <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEIVERN,II'I/SERVICES <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 /> 1600 Durham Ferry Road Hwy 33 Trac 95376 Assessors <br /> WELL Location �' Cross Street City Y Zip Parcel# 255-100-04 <br /> V✓ <br /> PROPERTYGeor e&Mei Teranishi 1600 Durham Ferry Road <br /> Owner 9 Address CityTracy Zip95376 phone# (209)835-3596 <br /> C-57 Contractor RSI Drilling Address 220 N.East Street CityWoodland Zip Lic#802334 phone# (530)668-2424 <br /> Consultant/Sub Cntr Geological Technics Inc. Address 1101 7th Street City Modesto Lic# N/A Phone# (209)522-4119 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> )a WELL# SW-102 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: See Workplan dated 09/26/07 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS See Workplan dated 09/26/07 <br /> ))}MONITORING )D:HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See Workplan dated 09/26/07 <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, s a ations,and all applicable California State Laws. <br /> Signed x (( V Title/Company , <br /> Print Name l 1 Y\. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: // 0,/2(16'7 <br /> Application Accepted By /V!B/�-ti�Lt�,% Date Issued 1r�2/{ �� Area Sys <br /> Grout Inspection By /LZ q Date G ZJ G Z Final Inspection By /v'G y Date 'g� ZS- Le <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3<< zjy 1383•`` o2(�fly (,v,,2 3/9/0S SR# 005,{ 322 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EI-ID 29-02-001 <br /> 6122/04 <br />