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. San Joaquin County . <br /> � OL <br /> z' � � <br /> Environmental Health Department SITE <br /> 0500-E. Main Street, Stockton,CA 95202-3029 <br /> ' MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.5jgov.org/ehd <br /> PR 1 7 2008UNIT IV <br /> Well Permit Application <br /> ENppppVIRQrr NIENT t W—JWFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is her�b�r A4 t&fRJrd r 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 9-1195.3 and the Standards of San Joaquin County Environmental Health Department. <br /> C 1 C rt EI Assessors <br /> WELL Location S Cross Street MACAlit'HVR, City .95 ��'Parcel# <br /> PROPERTY SAN 10AQViN COVN" diT11rE <br /> Owner_FACILITIES M(rNT. DEPT. Address 1122 t,SCoTTS AVE, City STI}C�Tom :.Zipy3105 Phone# <br /> WESTEF14 R1=saVIICE ErTRv> _ I <br /> C-57 Contractor_MMI <br /> _A14f.EENT Address rtO 00x 9 City�FFiGNTi_Zip9-J621 Lic#VS81G3Phone#S E)'4x-9-1-466 <br /> '{ 5 Si HLAI)bWS Pr,wY, PSG, T <br /> Cons...... Sub RAMRtri� EiVil,� IN Address 'Z Gity EH4 Lio# Phone# (1101051-1230 <br /> GIS Coordinates:X ,Y ,Township Range Section I <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER" _ 'i <br /> M_�_`.._ r^ _ w-- -�. ., }_ _d DESTRUCTION (choose type below) <br /> �-' —0 SOIL BORING°#� `� s" '"" 0 OVER-BO ER 0iAM1ETER -' <br /> a WELL# a PRESSURE GROUT <br /> M'Other V-Itom , V GROUT SPECIFICATIONS i! <br /> COMMENTS: !G Soft VArox SAMPLE I_aCATICNs <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING ,, a HOLLOW STEM DIA.OF BOREHOLE 7,11 a MULTIPLE CASINGS 0 MULTI-LEVEL WELL'CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING:-a STEEL a PVC - a OTHER;- . <br /> $VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA TREMIE TYPE TO BE USED: flAUGERS ©HOSE <br /> a AIR SPARGE!OZONE jr.PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'a Yes Q No (NOTE: MAXIMUM FREE-FALL DEPT_H IS 30). <br /> SOIL BORING N o HAND AUGER .. GROUT SREGIFIGATIONS._-N i=AT_,C C ISI-(�E'� - . -- - <br /> OTHER: 0 OTHER APPROX.BORING DEPTH_ S r [I BOLTED TRAFFIC BOX or In STOVE PIPE <br /> .- _ <br /> -CONDUCTOR CASING,PROPOSED N-0_. " (if'.YES,list.specification-in comment section) <br /> COMM'ENrs: RAMAL-C v. w iir. PiAN (I'If <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 j <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed Title/Company_I'RF5tGENT.� �AI1pCf E �I�VylZpjllM�l�rj{L� 10, <br /> `Prsnt Name-�a S C p�I M�'e Ea :w r'.:s.�.. r -k... w.�ti.-6w v. .rw.!s�Data - <br /> A DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV.FILE,ADDRESS: Sfl <br /> WORK PLAN DATED: rs( }I <br /> Application Accepted By Date Issued_ °-1 1 z% 109' .. Area . <br /> Grout Inspection By I A>r%A,,,._e Date '! Final Inspection By TT. Dale <br /> Destruction Inspection By Date �. <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: [j. :AID#.; y ..:•�e� ,p. s ',1: .- <br /> FAC#' _ <br /> Pt=CODES. FEE INFO AMOUNT REMITTED CHECK# REC'D BY t]ATE - PERMIT]SERVICE REQUEST# INVOICE <br /> x�'y fr o0 <br /> 'zf 36 '� zt eS SR# <br /> 3 z Ick . .5.3 ` .3 <br /> C-57 WC -WAIVER C-57 Letter.of Authorization to Sign permit ✓ Encroachment doc� <br /> I]HD 29-02-001web <br /> 6122104 <br />