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USAN JOAQUIN COUNTY � <br /> ENVIRONMENTA_ _ 'EALTH DEPARTMEN SITE <br /> :.p 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209) 468-3449 Fax: (209) 468-3433 Web:www.sJgov.org/ehd UNIT IV <br /> ,.:. <br /> .q�/voRN <br /> 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 /> Assessor's <br /> Well Location 821 SOUTH WILSON WAYCross Street EAST TAYLOR City STOCKTON Zip 95202 Parcel# 1§1-31&960 <br /> Property VICTOR ARANDA821 SOUTH WILSON WAY STOCKTON 95202 (209)464-8675 <br /> Owner Address City Zip Phone# <br /> CASCADE DRILLING 3632 OLMEC CIRCLE RANCHO CORDOVA95742 717510(916)638-1169 <br /> C-57 Contractor Address City Zip Lic# Phone <br /> ADVANCED GEOENVIRONMENTAL 837 SHAW ROAD STOCKTON 680227 (209) 467-1006 <br /> Consultant/Sub Cntr Address City Lic# Phone <br /> GIs Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> M NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# [IOVER-BOREDIAMETER <br /> ®WELL# MW- - - an - ❑PRESSURE GROUT <br /> []*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Install four on-site wells: MW-5(551) , MW-7(75') , SVE-1& SVE-2 (351 ) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1"i <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE�.e�/ <br /> El MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRrVEN CASING THICKNESS TYPE OF CASING:❑STEEL XPVC ❑ OTHER <br /> r i / <br /> VAPOR 1-1MUDROTARY DEPTH OF GROUT SEAL 31 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:9Yes ❑No (NOTE: MAXIMUM FREE--FALL ') <br /> DEPTH IS 30 <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS IVDP JI Pa-+6M 6eme.n-- <br /> 0 OTHER: ❑OTHER: APPROX.BORING DEPTH .SCJ" 7 /S ' 3S ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES•list spsciticeticns in comment section) <br /> COMMENTS: SrMsn't LZ9i.1*P x1 -35" is-SS" 70-7S7 <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, pd all appiic Is alifornia Laws. c q J /'� <br /> Signed � ; (,f �1�j.Ly[tyt.><'C� Title/Company �7�GC --OCA *f! /YL�tare d Crcd i i^wr <br /> Print Name 1*"L (- 4 l�-t'rr /1/1 -� Date 111-Al-09 <br /> �7 <br /> DEPARTMENT USE ONLY <br /> Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> / <br /> WORK PLAN DATED: eZ I 0 <br /> APPLICATION ACCEPTED BY q DATE ISSUED 1(3 a AREA y <br /> GROUT INSPECTION BY A �Y QO FINAL INSPECTION B DATE � � GO <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# 1 INVOICE <br /> 15 0 .2-q 11 3123 I&A3 d Y I SR#5-g5Y�L- <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />