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PAN <br />*an Joaquin County o <br />Environmental Health DepartmetW V SITE <br />600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/,4W, 2 Q 2007 UNIT IV <br />Well Permit Application ENVIRONMENT HEAL 4 - <br />PERM IT/SERVICES -- <br />PERMIT/SERVICES <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 />!, -1 /� Assessors <br />WELL Location lj�ve0 /"ri✓��3ali (, J aVCrossStreet Sy'i,ivlSc2n 44 City Sf"OCkt0tA Zip QO(. Parcel# f 722t`( <br />PROPERTY ^ `� ( ( !, <br />Owner' r iw M6"` V'r�ddress 5>5 0Q) C. 0CAC- CityS[xC✓Gv`1twtUZip rj�7��iPhone#_Cj[f 6.S7-5600 <br />/ )J �✓ I �I SU IDw� ��( Cit p 4SS" Lic# Y$ If:�"Phone# Ci1S31 <br />C-57 Contractor 1 r1 a Address y NK4 r i11 C ZZi <br />onsultan Sub Cntr'alp Address -28'70 (ca.`F� ma4 (1Lck�City wl w ic# Phone#(rC�� v Irl - f� <br />1. � •, Township <br />GIS Coordinates: X Y ! Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / ORIS �GEOPROBE HYDROPUNC AND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />0 SOIL BORING # S r3 _ >~ CPT -I (dr - Y 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other �GROUT SPECIFICATIONS <br />COMMENTS: o ((mow <br />CPT i�c7 C �tclC� --- <br />J <br />TYPE OF WELL I TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING HOLLOW STEM DIA. OF BOREHOLE0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ N� <br />0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: v-4 <br />0 VAPOR 0 MUD ROTARY ---DEPTH OF GROUT SEAL Q TD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or&GROUT <br />ROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30 SOIL BORING 0 HAND AUGER SPECIFICATIONS ke "'f <br />0 OTHER: OTHER C +�T APPROX. BORING DEPTH j �� L` _)a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />�y'����G <br />Signed x Title/Company <br />` ( <br />Print Name �,- T I D-0 Date 1 d <br />V � �"� <br />DEPARTMENT USE ONLY 79 /n A <br />SITE MAP IN UNIT IV FILE, AD <br />WORK PLAN DATED: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITION; <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />1Ll o l , 55 <br />y <br />Date . <br />-Date Final Inspection By <br />Date / <br />ruulf <br />r/AU4 <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />0--4- <br />� <br />%:�. <br />g -20 <br />SR# 0 1 �S�O <br />. <br />A <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc-NM <br />EHD 29-02-001 web <br />6/22/04 <br />