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ip vSAN JOAQUIN COUNTY 41"110,ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 SITE Telephone:(209)468-3454 Fax:(209)468-3433 Web:WWW sigov org/ehd MITIGATION UNIT IV WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, Well Location 2403 Navy Dave Cross Street Kam Ss"I Assessor's Property City srodcron Zip 95203 Parcel# les "2 Owner Cl,abe Tc Address 1385Moss,.WA.. City Esralon ZIP 952120 Phone# (20)947-1727 C-57 Contractor Gregg Drilling Address 9`�Hoxe Road City MaNnez Zi 90.553 48518s Zip Lic# Phone Consultant/Sub Cntr ATC Associates Address 1117 Lone Palm c Modesto h Lic#WA Phone (209)579-2221 GIS Coordinates:X ,Y ,Township Range Section WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) N SOIL BORING# sa-101 ❑OVER-BORE DIAMETER El WELL t [I PRESSURE GROUT El`OTHER GROUT SPECIFICATIONS ❑EXPLOSIVES DETONATING CARD COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL PVC ❑ OTHER _ ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') IN SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING PROPOSED (it YES,tist aped8rationa in commem section) NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,and"qjllcable California Laws. Signed I Tide/Company 1 M 57 AC14,6c-j�,4e ) Print Name -y, DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: /r.GNt/ A- f. SlkW. L6V-'S.Xc ifeebt. 302-3 WORK PLAN DATED: ^W4 L '2�0U APPLICATION ACCEPTED B�,I19(,_��L/� DATE'IS'SUUED '�,LI ;2W'O AREA )�J GROUT INSPECTION BY AT!'^� FINAL INSPECTION BY ( - DATES �/ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID* FAC If PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE ( .c iyi ►2i `15�4�&4 �!{t: 5y ,V/1 SR# bpi C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 10/28/09 �-163 3&b 3�6 gYv�s /�1_�i /iL �// 2v WELLPERMITAPP [ T