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f <br /> �4 <br /> r-QU " SAN JOAQUIN COUNTY <br /> x1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton CA 95202-3029 MITIGATION <br /> W_'iwz� <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sicloV.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUtID68LE 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 C my Environmental Health Department. 11-7 016 0 7 <br /> ¢-- Assessors <br /> Well Locatlon2 4 17 West Lane Cross street Klin er Road city Stockton Zip 95205 parcel# 117-09 0f <br /> Property <br /> Owner Joseph Rokoszewski Address 2417 West Lane Gitvstockton Zlp 95205 Phone# 916-729-176, <br /> C•57 Contractor WRM Address BOX $93 8 1(y citrus Heights LIc# 888763 Phone 91.6-72 9-176 0 <br /> Consultant/Sub Cntr WRM Address Box 8938 ity citrus Heights Lic# 888763 Phone 916-72 9-176 0 <br /> R GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> IN NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING# 1 Borings ❑OVER-BORE DIAMETER <br /> ❑WELL# Ll PRESSURE GROUT <br /> [I*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: SOil Boring to 701 and collect soil and crround water sem les <br /> TYPE OF WELL INSTALLATION TYPE TRUCTIQN_SPECII'ICATIONS , <br /> ❑MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8 rr ❑MULTIPLE CASINGS❑MULTI-LEVEL. WELL CASING DIA <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> /'\iR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:®)es ❑No (NOTE: AXIMUM FREE-FALL DEPTH IS 301 <br /> F ®'SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: T ❑OTHER: APPROX.BORING DEPTH 70 Feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> - <br /> COMMENTS: CONDUCTOR CASING PROPO D (If YES,1i1 specMait om In carrmnt smfian) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS <br /> C48 WORKING HOURS NOTICE REQUIRE FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I a cordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Titte/Company en' G la t WRM <br /> Print Name Thomas E. Ballard Date April 13, 2009 <br /> DEPARTMENT USE ONLY <br /> k ` i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: —7 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY `771 . DATE ISSUED AREA�C{y <br /> GROUT INSPECTION BY FINAL INS DECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: W Rim �I <br /> �F <br /> TING ONLY: AID# FAC# <br /> an <br /> S FEE INFO AMT REMITTED le"W t 2C RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Fj <br /> T 3563Ll <br /> 3i c> yo� otv���}�j ""tYZ d SR#S d C-57 WC -WAIVER C57 LETTER OF AUTHORIZATE N TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 1115107(WEB) WELL PERMIT APP <br />�Y <br /> L i <br />