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man Joaquin County <br /> sa Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 DEC 14 ZOMITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> �IFORN,P . EPdVIRQv+��1�T NEAL�I�IIT IV <br /> Well Permit Application WERl1T/SE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> 2969 Loomis Road Hwy 99Stockton 95252 Assessors 179-11-024 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY Margaret Marci (707)465-6015 <br /> Owner g Address 20 Mobile Lane City Cresent City Zip 95531 Phone# <br /> C-57 Contractor Resonant Sonic Drilling Address 220 N East Street City Woodland Zip 95776 Lic#802334 Phone#(530)668-2424 <br /> Consultant/Sub Cntr Geological Technics Inc. Address 1172 Kansas Avenue City Modesto Lic# N/A Phone# (209)522-4119 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> WNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# EW-4 thru EW-6 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFI T S <br /> COMMENTS: See Revised Work Plan dated 1/23/2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D;EXTRACTION (3) 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:_a 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 Revised Work Plan dated 1/23/2009 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances les and R ulations,and all applicable California State Laws. <br /> Signed x Title/Company ;[QA C S�(��� /�j= ;t�'�lam¢-, <br /> Print Name 1 Date 1 Z01 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2 g G q L O o M i s <br /> WORK PLAN DATED: J4:r1(La r^ a3_ .200 9 <br /> Application Accepted B1� �n 1 r Gr L I Y L C(d r+a u,-Date Issued D ed e mb G'Y 22 2g20� Area J4�_ <br /> Grout Inspection By r if`i st C.mC�d!t f7 Date f-Ig '/Q Final Inspection By Yi r trri,._���Date L" /U <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Y - -S r e <br /> ACCOUNTING ONLY: AID# FAC# �P <br /> L <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 501 E9.6o - <br /> sd 3 s,aa 4.4,• 00 2 219y9 1149 Irl /2-22--01 SR# 00 59 02 7 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />