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SEP. 24. 2007 7 , 50 M PAR"ONS-425-979-9701 NO. b17S—P, 2^- <br /> �o o San Joaquin County <br /> z <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax- (209)468-3433 Web: www_sjgoy.org/ehd 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 Deg lop lent Title,Chapter 9.1115-3 and the Sta¢dards of San Joaquin County Environmental Health Department. ,�I <br /> L(` .� ,K}y r or 7- Assessors 'YO r1 <br /> WELL Locatlo Cross Street�l city-Q1n _ZIpq'�-2n� Parcel <br /> PROPERTY <br /> ownerCj'iLA If Address 5kty Dna(o,,a4�-, _Cily2)6���ZipC!�X2Phone#149 ��� <br /> C-57 Contractorll 4 y ddressqC1l-H(]yo t1C 1 Ci1ty Q Zip�3Llc#�$�bS Phone* 0X,-)- +3-*00 <br /> Consultant/Sub Cntr 76MQKh Address.00,LLMO, "��+JC1( City AIVtW�((raLiC$ZZ_(aQLtk Phone#025) cW-3 <br /> GIS Coordinates:X ,Y Township Iy Range ,Da Section Z` l <br /> WORK TO BE PEREORMED- <br /> IWNEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) n DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 'j6VELL it MW I' Mhl-1� n PRESSURE GROUT <br /> `0*Other GROUT SPECIFICATIONS <br /> COMMENTS:aj�j 10 ` i (� (�I { iQ In�OP �!(l (� D 11 � <br /> TYPE OF WELL INSTALLATION TYPE QONSTRUCTIONE IFICATIONS <br /> MON TORING HOLLOW STEM DIA.OF BOREHOL rl 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA'2-T <br /> n EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS SCIt TYPE OF CASING: Q STEEL XPVC 0 OTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL�TREMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED' Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER; 0 OTHER APPROX.BORING DEPTH IOO`,4- BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> f GL� CONDUCTOR CASING PROPOSED Mrd (If YES,list speciflcatlons in comment section) <br /> COMMENTS: "�Lr2 `C W I I d " /O l <br /> l- 44 -110 4- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 49 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> 1 hereby certify that I have a ared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi s Rul egulations, and all applicable California State Laws. G <br /> Signed x Title/Company T t 506J J <br /> Print NameDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S <br /> WORK PLAN DATED:✓�� ()1 d-b de— () 1 <br /> Appllcation Accepted By /y\ Date Issued it 130 I Area 9L[y <br /> Grout Inspection By lDate 12-13 O Final Inspection By (X-� Date I Z- 0 — <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT/SERVICE REQUEST* INVOICE <br /> SR# 5 <br /> C-57, WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> BHD 29-02-OOl WEB <br /> 9/11/2007 FiLE C <br />