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San Joaquin County <br /> S Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Fax: ( : www.sjgov.org/ehd <br /> (209)468-3449 F209)468-3433 Web <br /> � 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 /> IV Assessors <br /> WELL Locatiofn_ �ZO S\�S �S� 6a��pcs c. Ir°�Cross Street �^" m� City S40-'"�Zip Parcel# 173 -040- 3a <br /> PROP <br /> RZf <br /> Owner E -✓'YyV�CI c. 4 w Address 64eA'1-0c, sr(()a city ikS <br /> o )M/� Zip '7� 3 <br /> � Phone#g4-Z93- 000 <br /> C-57 Contractor �� Address .O IJJX �� City y.6dL1 Zip5141 Lid TZO`/0'f Phone#ZO0! Vq - 1(100 <br /> CC y�� Q <br /> Consuhant/Sub Cntr � J-1- Address 1` -L S� 3 Citvt2i( -y Lic# �Z�O <br /> GIS Coordinates:X ,Y ,Township Range e <br /> WORK TO BE PERFORMED: JAN 1 8 2008 <br /> EW WELL I(W?R <br /> JKO (CPT, EOPROB ,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> a SOIL BORING# �� a OVER-BORE. DIe i <br /> a WELL# KPRESSURE GR °TfaA,a ,,-nor irLTH <br /> a*Other GROUT SPECIFICATI8�/�,f J�Rl/IrES <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING T)HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE]OZONE #PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes n No (10 7E: AXIMUM F6E E-FA//DEP7 HIS 30') <br /> , OIL BORING aHAND AUGER GROUT SPECIFICATIONS C-CmeAl <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH ?-04-60 a BOLTED TRAFFIC BOX or a 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 /> 4U WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I her cerci f8va=prepared this application and that the work will be done in accordance with San Joaquin <br /> C my Ordina sl R lend Regulationsl and all applicable California State Laws. <br /> Signed x Title/Company --� - <br /> Print Named Date ( I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ADDRESS: .ZOO' . /'ALA�, /_.,) S+6��l <br /> WORK PLAN DATED: 7 <br /> Application Accepted By Date Issued Z oO Area a <br /> _ <br /> Grout Inspection By Date 0 Final Inspection By Date / <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE PERMIT/SERVICE REQUEST# P <br /> �90i tf- Bq- ��y � / 1" aY SR# 003 3l $ ' <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29.02-001 WEB <br /> 9/11/2007 <br />