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C <br /> San Joaquin Count <br /> Enviroi;mental Health Department ITE <br /> 600 East Main Street, Stockton, CA 95202-3029 ` 'f ; i 20MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 web: www.sjgov.or�X �,�r4 �E�jr HErtiLTN NIT IV <br /> Well Permit Application p`- SIT/SERV!„ <br /> ES <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 /> Assessors <br /> WELL Location 975 SOUTH FAIRMONT AVE Cross Street KETTLEMAN City LODI Zip 95240 Parcel# <br /> PROPERTY <br /> Owner LODI MEMORIAL HOSPITAL Address 975 S FAIRMONT City LODI Zip 95240 Phone#209-334-3411 <br /> C-57 Contractor KMC,INC. Address 6691 BRISA City LIVERMORE Zip 94550 Lic# Phone#925-245-6205 <br /> Consultant/Sub Cntr WESTERN PUMP,INC. Address 3235 F STREET City SAN DIEGO Lic#673853 Phone#619-239-9988 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> X*Other GROUT SPECIFICATIONS <br /> COMMENTS: ENHANCED LEAK DETECTION TO BE DONE BY CGRS <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 /> a 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:_0 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: <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Date r TF(ti�� ,_y T <br /> KrU+-5'- DEPARTMENT USE ONLY �If✓h 2 <br /> SITE MAP IN I INTI III ILE,ADDRESS: "l S �� God--' av, g �'J!" <br /> WORK PLAN DATED: I �// NIRZ-1t-%V QU/�— <br /> Application Accepted By ( .C.�- �T 1� Date Issued t ` y 0 TA—PA_N 0 �� <br /> -VP <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> g , UD g 3"? 132 o T S R#ro�0 Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />