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Nan Joaquin County <br />Environmental Health Department HEM <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />{ SITE <br />MITIGATION <br />(209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdOEC 1 7 2007 UNIT IV <br />Well Permit Application ENVIRONMENT HEALTm <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM1T/SERVICES <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 />WELL Location 32 (.; LA N Cross Street <br /> Atigi Z.. Assessors <br />WEST 14/ AA- City srocs-ro-) r Zip 95L Parcel# i/ 7 <br />PROPERTY <br />Owner strnoRA BA•Ke ( Address I Sc., 7 9 S3 (e Q City /400€5 TQ Zip 151511 Phone# t <br />C-57 Contractor G1 e ) Address 9 5 i-is:vy A)cl City/44,-7;n eLZipqq513 Lic# GrOr, / Phone* Z 0.3)1--.5"go <br />Consultant / Sub Cntr Advanced GeoEnvironmental Address R "47 q.kiaw Rd City Stockton Lic# 680227 Phone# (209)467-1006 <br /> <br />GIS Coordinates: X Y <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />B NEW WELL / BORING GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # P ais' <br />U WELL # <br />U *Other <br />COMMENTS: SE F l< PM N J <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />A cOe Igo evirror Loc\-2 ollsoizoo 7 <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 HOLLOW STEM DIA. OF BOREHOLE Z-' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 4-°9 <br />0 AIR HAMMER/DRIVEN CASING THICKNESS 4/4 TYPE OF CASING: 0 STEEL a PVC 0 OTHER: al, <br />a MUD ROTARY DEPTH OF GROUT SEALl= 75 TREMIE TYPE TO BE USED: D AUGERS A(HOSE <br />APUSH POINT (GP or01j4GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />13 HAND AUGER GROUT SPECIFICATIONS 41 7 bind) ery, F. lf--- <br />0 OTHER APPROX. BORING DEPTH 75 F&c fr 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED /1/4/bi (if YES, list specifications in comment section) <br />E /)O- A io,Rc, .. A ) )'' V r - dr) 1(0 iy Lzit ,, / <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 />Signed x iW4 Itrt, etAilli___ Title/Company Ro'3e0" (s:o/q)5i'>7 <br />Print Name / , ,,,, 0 -1-1.4 1 J,, (qE-)1,44_ Date jag / -7/ <br />WORK PLAN DATED: 5ep I- 447 e ,- -0 2&7 .-2,o1 ce 717 5 12 er- /6-, 2 c r) '7 <br />i , <br />Application Accepted By 1" jr,7ery-:4_ 2, , /12e- : 4 r --17 / ez. Date Issued /-.. - I S) -6 Area i 4-s---y- <br />Grout Inspection By ii t,71-tret 4 Me. 24 r 1-",g4.? Date 2- S Final Inspection By V 4' Cjilr; 4. ii/elearfrite.fate 2 -2-1 -08 <br />Destruction Inspection By Date <br />COMMENTS! CONDITIONS: 4dk14 r1 4J ni./..-4_1 0 tkole - 19-1B <br />ACCOUNTING ONLY AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ERVIC • i• - T # <br />_ <br />INVOICE <br />3.5-6 3 3.5-D / <br />2960 , <br />.3, e i. 6 6 .2 (c 7//, L. G .717 i2-ig-a '7 ' R# 0 q 7/ , <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />TYPE OF WELL <br />a MONITORING <br />a EXTRACTION <br />O VAPOR <br />0 AIR SPARGE/ OZONE <br />*SOIL BORING <br />0 OTHER: <br />COMMENTS: SEE <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 32 3c N Wes± Lan e <br />EHD 29-02-001 <br />6/22/04