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UI <br /> �p )San Joaquin County t <br /> _ Environmental.Health Depart SITE <br /> 304 East Weber Avenue;3rd Floor;Stockton, C � �� DID MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or ehd UNIT IV <br /> Well, Permit Application . $ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM-DATE'' A!_Ti-t " <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work"descri ed."ThhlappjlldetU 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 /> WELL Locatlon 4716 E ST RT 88 'HWYAssessors <br /> Cross Street Cherryland Ave City, Stockton Zip 95215 Parcel# 101-021-23 <br /> PROPERTY <br /> Owner RAumgAcK, ARCIT P. Address__L4_4_GLEN OAKDR Ci LODI <br /> ty Zip 95242.• Phone# 209-334-3188 <br /> C-57Contractor Mitchell Drill in Address 7900 M rtle Ave City-Lu.reka Zip9SS03 Ljd#672617 Phone# 707-444-9040 <br /> Consultant Sub Cntr AdyanCe4 GeoRnyi1aamcatza Address 837 Shaw Rd. —Cityztoc inn Lic#" 680227. Phone# 209,467-1006 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> SWELL# MW-11,MW-12.MW-13,MW-14 0"PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE" CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING ff HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: 2" <br /> ©EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCD 4 0 .TYPE OF CASING: o STEEL 0 PVC p OTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 50' TRE MIE TYPE TO BE USED:, ff AUGERS a HOSE <br /> Q AIR SPARGE!OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FA11 DEPTH IS 30') <br /> 9 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS -Portland-Tye_ II <br /> Q OTHER: a OTHER APPROX.BORING DEPTH 85' ;&BOLTED TRAFFIC BOX or a STOVE PIPE <br />€ CONDUCTOR CASING PROPOSED NA. =(if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U 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 Ord'n nces Rules a d Regulations and all applicable California State Laws. <br /> I . <br /> Signed x Tit]elCompany Staff-ScientistLAdvanced GeoEnvironmental <br /> Print Name Ally Colavita Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: lk py_ <br /> WORK PLAN DATED: �q <br /> Application Accepted 8y Date Issued_ Z t �a Area <br /> Grout Inspection By Dated O Final Inspection By . ��-ti�Ew, Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES_ FEE INFO AMOUNT REMITTED CHECK# 5 EC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> z rod S R# <br /> 3s�'1 �z�•aa 2.(��af � l { 53�z� <br /> G57_ WC -WAIVER— C-57 Letter of Authorization to sign permit_/Encroachment doc✓ <br /> EHD 29-02.001 <br /> 6122/04 <br /> k <br /> n <br />