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I'dw, <br />ARAj! <br />Oan Joaquin County o <br />E E�y <br />Environmental Health DepartmedIV SITE <br />600 E. Main Street Stockton, CA 95202-3029 MITIGATION <br />1 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/14ucl 2 0 2007 UNIT IV <br />Well Permit Application ENVIRONMENT HEA' H <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 />vU ` 4 �E,Cross Street.QAssessors <br />WELL Location RktC C <br />Parcel# 11)Z6CIC)�� <br />PROPERTY �1 ``� II -- <br />Owner 'A Apo,, 0,,Co o l?Vcz,, c1dress S(*"'yeAe_ <br />. 9, CitySC.(✓uvAeJuZip iJ2)Phone# VS <br />C-57 Contractor 9,^e�tj Address 1,T0 rti-3G0� <br />' s <br />!Nwn SYs�"Sy <br />onsultan Sub Cntr Ltl�S Address.2870 CJrz�tw:c: Phone# (qlb) 67 c 2000 <br />GIS Coordinates: X 1. Oa Y —t 2-1 • , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL /(9ORIN CEj)GE�JI O`l PROBE HYDROPUNC AND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />1] SOIL BORING # S R - -f- 3 c+ S 9- C CPT -1 t1Ad'o✓)vt (di- V 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: Ci fro ao�iz --,> ��� �v'c t/' i��s�c�Olrs s Ll CN I [3 4tcic5 --- <br />TYPE OF WELL 1148TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE�r 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA. <br />0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: V4 <br />0 VAPOR 0 MUD ROTARYEPTH OF GROUT SEAL 0 rb TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP orOPT)(ROUT SEAL PUMPED: aYes 0No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />)11�SOIL BORING 0 HAND AUGER ROUT SPECIFICATIONS .t!/cwf iC,�ii <br />0 OTHER:OTHER C.{>T APPROX. BORING DEPTH,j cn C-I;J �4 5-' � 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />e-% / w 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 />SignedTitle/Company <br />x � <br />Print <br />ter', � I , � ec-' <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />I =-0 <br />DEPARTMENT USE ONLY <br />S: <br />Date Issued_ Area vQ <br />Date Final Inspection By —Mlle 9" Z" <br />Date <br />E.1 <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />�O¢akt <br />g �ZO <br />SR# Q�I7�J�G <br />C-57_ WC V -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc m <br />EHD 29-02-001 web <br />6/22/04 <br />