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i Ig <br /> �zD SAN JOAQUIN COUNTY <br /> ( ya ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> {" 600 East Main Street, Stockton , CA 95202-3029 MITIGATION <br /> Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.s'gov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION P F <br /> FILE COP Y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED ' - <br /> f <br /> Application is hereby made to San Joaquin County fora permitto construct andfor'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 /> . . Assessor's <br /> Well LocatIon3to5 s e] Dorado St Cross Street Ivy Av , City Stockton Zip 95296 Parcel # 175 - 120 - 28 <br /> Property <br /> Owner Robert A . Ellis Address P . O . Box .6245 City Stockton 71p95206 Phone # <br /> C-57 Contractor WRM Address Box 8938 City citrus Heights LIC # 888763 Phone ( 916 ) 371-1690 <br /> Consultant/Sub Cntr WRM Address Box 8938 City citrus Heights Lic # 888763 Phone I ( 916 ) 371 - 1690 <br /> GIS Coordinates: X , Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER`) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> ❑ WELL # ❑ PRESSURE GROUT <br /> ® `OTHER GOf 1 Vapor � GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 2 " ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _ <br /> ❑ EXTRACTION ❑ AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br /> VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL 2 I TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br /> ❑ AIR SPARGE/OZONE ® PUSH POINT (GP OR CPT)9P GROUT SEAL PUMPED: p Yes W No (NOTE: MAXIMUM FREE-FALLAEPTH IS 30') <br /> ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS <br /> ❑ OTHER: ❑ OTHER: APPROX BORING DEPTH 5 I ❑ BOLTED TRAFFIC BOX OR ❑ STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (if YES, fist specifications in mmment sectlan) <br /> COMMENTS: <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 I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, and all applicable California Laws. <br /> Signed � t ,_�. �.... Title/company Senior , Geologist /WRM <br /> Print Name Thomas E . Ballard Date / /,x / 09 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3 1 Q or- 5. D a -rQ d � 1 O J 1 )r e E l� <br /> WORK PLAN DATED: June` t _I 4 zD D q <br /> APPLICATION ACCEPTED B,Y/ V 1 Gro Y' i IX Mc Cl a r -�-n e v DATE1 'ISSUED 611a. 101? AREA 14.9 <br /> GROUT INSPECTION BY �V 1 Pl7PCIA L 0jul4rh" FINAL INSPECTION BYV Gni IT !`ihrnLL�-1- DATEGIS 0 I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: Advao YYte�r1 to S1) 71 1'JoYI riQS SV/ 1 . SY - 3 SV - $ Qnd 5V/ Y <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> rtdl Gpr poy ?Ar <br /> Dl) <br /> SU a s. UD 2 V /n G / 2 p SR# 00 517.54 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DOC <br /> EHD 28-01 1115/07 (W EB) WELL PERMIT APP <br />