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A° '^ SAN JOAQUIN COUNTY <br /> a <br /> ENVONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 TION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:=.s' ov. IV <br /> WELL PERMIT APPLICATION DEC - 7 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUgVIRDNMEINT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicRi6k M1♦ &6PWGESnce with San <br /> Joaquin County Development This,chapter 9-1115.3 and the Standards of Sen Joaquin County Environmental Health Department. <br /> Rainwater Car Wash 420 West Yosemite Avenue Manteca 95337 Assessor's <br /> Well Location Cross Street - City Zip Parcel# 219-312-06 <br /> Property Phillip Elder 420 West Yosemtie Avuene Manteca zip 95337 Phone#1-209-462-0652 <br /> Owner Address City <br /> Greggddress City L <br /> C-57 Contractorc# Phone <br /> re Drilling 950 Howe Road Martinez 485165 1-925-313-5800 <br /> Advance GeoEnvironmental Inc. 837 Shaw Road Stockton 1-209-467-1006 <br /> Consultant/SubCntr Address City Lic# Phone <br /> GIS Coordinates:X 'y ,Township Range Section <br /> �WORK TO BE PERFORMED: <br /> r�NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> Z SOIL BORING# - ❑OVER-BORE DIAMETER <br /> Zx WELL# EW-2 and EW-3 ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 12 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA[_ 6 <br /> ill EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS kX '1O TYPE OF CASING:IVTEE`El! PVw„4 OTHER <br /> []VAPOR [IMUD ROTARY DEPTH OF GROUT SEAL 1-34 TREMIE TYPE TO e``E USED 0 AUGERS Z HOSE <br /> ❑AIR SPARGEJOZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:®Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> Z OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifmtiom In comment"dim) <br /> COMMENTS:_ <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,and all a Iica a Califomjy��Laws. 1 - <br /> Signed ,/-�p� ///t�G%.2.L, Tile/Company <br /> Print Name Com'//i rko Dated � 9 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: G� W y OS.Qµ'r” / � ILA A^ <br /> WORK PLAN DATED: r"L � o <br /> APPLICATION ACCEPTED BY tel. DAT I' AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION B DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEE INFO AMT REMITTEDCHECK# Rill ILPERIIE# <br /> ILI INVOICE <br /> 0 ->oAAG l <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD29-01 116107(VIES) WELLPERMITAPP <br />