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r•N <br />—q c .an Joaquin County <br />Environmental Health Department OCT 1 1 2007 SITE <br />600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.iii-WiffNMENT HEALTH <br />DC:01‘/IfT,/t;i:M1 UNIT IV <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 />S'A 0 A 0, S 111 _ Assessors <br />WELL Location Z2L E, riEl3EN AvE Cross Street 5 rmEEr City 5 'RC ti T04 Zip ':)514 CZ Parcel# 4 9' 1 CO I <br />PROPERTY SA N 70/10,viN COVNry <br />Owner EACilt FIES wiGlir. a l'T.Address 1122 E. 5coir5 City 5tGcts re t`l Zip 9 52C Phone# (2.G.9) E 9t-12 <br />WESTERN MES0iiiCE <br />C-57 Contractor MANA0-E Ma NI- Address ViO, BOX e93 Citsuc <br />Cityl4FIGATS Zip 95V4 I Lic#Yai(3Phone# (3116)129 1 1 42 0 <br />Consultant/ Sub Cntr 11ANA0E ENV., I N C, Address '4". "EA" W'; 11 1C114ity\*Rt lt,1%-11 <br /> <br />:1 svi-Lic# t Phone# unc) ?.0 I -7 2,3.9 <br />osi.1 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />B NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) g DESTRUCTION (choose type below) <br />1:1 SOIL BORING # <br />OVER-BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />I *Other V-1, V -1, , V -3 V - V <br />COMMENTS. 5 ',Meek SAmeLE Lor ricN5 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2. 11 a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Ii A TYPE OF CASING: 0 STEEL a PVC g OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL C 1 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nr_ Al cE 11E KT <br />l:I OTHER: 0 OTHER APPROX. BORING DEPTH S i a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED ril 0 <br />COMMENTS: 6At.1 A-0-E E-Nv, INCA 1-< PLA-N ( ill -f-i01) <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />KED <br />GROUT SPECIFICATIONS <br />(if YES, list specifications in comment section) <br />Signed x <br />Print Name ,Toe_eo 111-km E <br />Title/Company NE.5 to RAJ(' RAMAc-E ENV 3CINtlE firm, INC, <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2-22 East We Joe,r Aver/ ike. <br />WORK PLAN DATED: July .27) 02O0 7 <br /> <br />Application Accepted By V ic.:1-04-1 tk MC 2.4 rtri e y Date Issued <br />Grout Inspection By V; ekrrY A MA, A ,--hutr,7 Date 1 / 2/Q 8 Final Inspection By <br />Destruction Inspection By Date <br />Area I 4 5 C? ‘I; 111e04-140-/Date e <br /> <br />COMMENTS / CONDITIONS: Ad YI CeY)IP 61+ t f -e;,e, soil hi 4s(V1 -14a r o %/AA 1:1 5') -Po r VO Or 5-am les <br /> 1 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE Ilwitaa-sowirF RFQUEST # INVOICE <br />35c i <br />5b3 <br />Jr <br />99. vo <br />ea' 94..00 <br />,t. 383. 00 .2464 t#171 /0 -/&-07(51‘t 0005- zsiser <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />EHD 29-02-001web <br />6/22/04