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1 Joaquin County <br /> i Environmental Health Department Ole SITE <br /> ` 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 04LrFDR�`P Well Permit Application <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 /> g2 SGV -Fh w•15or� 'J G Assessors <br /> WELL Locationd;t r, StecK-tens %2mt�'f crcross Street / T�' �C�city;��2''Ct*"G Zip /3�O Parcel# 1,5/-/ <br /> J ( o <br /> PROPER��'� (` , , ,�/ �� P ty, r C--+ iaV Zip honer '�i c1.�7`o-2C 6 , <br /> Owner C -�' tt' C7 �:•�7�`� Address�s!`� �-1 �°1t�' Ci ' <br /> :.,! 7chc ys W 7/ � <br /> C-57 Contracto S wt. Urfill' : Address•-�trr3 (almi�-f�rz.l cny,"50 " ziP �aF 7 CPhone#_ 6.3e?-444,2�i' <br /> �vv47CE / S GLS A(jc#rLJt9 7 <br /> Consultant/SubCntr�-2^- ulwiK�Gr �27zL� Addressb'37 S.�a. Rd Pnon -^ 7-%DDE• <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> x)TNEW WELL f BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# a PRESSURE GROUT <br /> a`Other GROUT SPECIFICATIONS <br /> COMMENTS: i/LrSiWU (9AIe 0GF-,5-ME XYI-126 nt %tX'Jl 7b -/D-16d <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFI_Cn TIONS i <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 12 <br /> U EXTRACTION a AIR HAMMERI)RIVEN CASING THICKNESS TYPE OF CASING: a STEEL •`Q�PVC OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL j 3f �1`- TREMIE TYPE TO BE U&ID: ,<UGERS a HOSE <br /> AIR SPARGE/OZONE 13 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes )(No f OTE: MAXIMUMIF�RE�E_-FA DEPTH 1 30') <br /> 11 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_ /X'/X'. -2T Por�T��U-[Li ceofCl2t <br /> p <br /> OTHER:_G OTHER APPROX.BORING DEPTH _�S r a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: !�7D $Ci['eiL` DYYf S�S5 ld- <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 Ordindne'es, Rules d Regulations, and all applicable California State Laws. S71aff , f�S <br /> i <br /> Title/Company Advanced GeoEnvironmental, Inc. <br /> Signed x /y .tet <br /> is arranza Dale <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a I S • W I ISO ✓\ <br /> WORK PLAN DATED: � ) I'Q 1 a <br /> Application Accepted By Date Issued `a a Area / T <br /> Grout Inspection By `17Date 6 D Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> D I (5 4 Q Zola 7h �d f`� $ SR# 5J U <br /> C-57_ <br /> WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />