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_ J <br /> • SAN JOAQUIN COUNTY L _ <br /> ENVIRONMENTAL HEALTH DEPAR TJc, SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ` Telephone:(209)468-3449 Fax:(209)468-3433 Web: ww dJg v Dr 4009 <br /> h G <br /> E� n lOIVi 1E jul- 0 � ''009 <br /> WELL PERMIT APPLICATI ,,V(. !�; tE"' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RVICC8 t/1R ,'Pl�trl'ci'!? )lEAt?H <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 /> Assessor's <br /> Well Location_5756 Pacific Ave._CrossStreet _ o.Ibi�nhood'JDr._City _Stockton_zip_95207_ Parcel q_10227010_ <br /> Property �'%!L'1% �(/ �.�s / <br /> Owner Address Zip f,LThgqone N o <br /> C-57 Contractor '�Q11 Address o City IZLic# �R hone /-a /��/Z <br /> - <br /> City <br /> Cntrp� � Address l �� Lic# Phone <br /> If <br /> GIS Coordinates:X Nwr v tel-315-•Township Range Section <br /> ZK TO BE PERFORMED: f <br /> EWWELLIBORING(CPT,GEOPROBE,HYDROPUNC , -AU E ,OTHER-) [:]DESTRUCTION(CHOOSE TYPE BELOW) <br /> E]SOIL BORING# ❑OVER-BORE DIAMETER <br /> g WELL# ❑ PRESSURE GROUT t^, • <br /> EJ-OTHER / / GROUT SPECIFICATIONS V <br /> SUE 2"PI/C &-W4yi leym? <br /> COMMENTS CJ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE _4"_ ❑MULTIPLE CASINGS❑MULTI-LEVELWELLCASING DI <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS_SChedule 40 TYPE OF CASING: El , <br /> STEEL �PLLVCE] OTHER _ <br /> I <br /> b/. ❑MUD ROTARY DEPTH OF GROUT SEA/�F66-r TREMIE TYPE TO BE USED ❑AUGERS❑HOSE <br /> ❑ 4 <br /> AIR SPARGE/OZONE -1 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED: ❑Yes 0.(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> J <br /> SOIL BORING Jr/HAND AUGER GROUT SPECIFICATIONS ✓'�"'• U r'1 <br /> hh/ <br /> ❑OTHER: ❑OTHER: APPROBORING DEPTH /U BOLTED TRAFFIC BOX E]STOVE PIPE <br /> CONDUCTOR <br /> TOR CASING PROPOSED (if VES,list specifications in comment section) \ <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 <br /> applicable California L <br /> / <br /> SignedA <br /> Title/Company_Senior Project Engineer/LFR,an ARCADIS Company <br /> Print Name E. Max MacLeod DateJuly 2,2009 <br /> DEPARTMENT U E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: — O <br /> APPLICATION ACCEPTED BY DATE ISSUED D AREA Obi <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES [FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> v6 U 103 2540 7-3-C2 <br /> C-57 C57 LEITL O ZATI N T - iNvER I R <br /> WELL PERMIT APP <br /> EMD 29-01 11/5107(WEB) <br />