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C(apy <br /> San Joaquin County [ <br /> Environmental Health Department SITE <br /> W. <br /> 600 East Main Street, Stockton, CA 95202-3029 OCT - 4 200MITIGATION <br /> 209 468-3449 Fax: 209 468-3433 Web: www.s' ov.o�/ hd <br /> �. ( ) ( ) �g (�/llCn;iia .C+�i 4�El�LTNUNIT IV <br /> Well Permit Application PERF P;I/SERVI -, <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 Joaquip County Environmental Health Department. <br /> �'QyrOn n ,j b Lumen ersm ;c�Ci'ultd / Assessors <br /> WELL Location > Fo &n W>Gk U Cross Street Wmjff City I/it Gy Zip 953o Parcel# I C ROW <br /> PROPERTY MOIAnfR't/i /40U5 ,{ �f I <br /> Owner(r,MtMUYti f J SCryices lij.Address Zi30s-5hfl d►/►g Dr CityM011�a�4&59ip 53 Phone# Y 31'2 Q r/ <br /> C-57 Contractor a /^+ Address M-MM. '� *-t''5"J,5trcet City �ftM(I�i Lic# 023 Phone# s� 6ro?-2072 y <br /> Consultant/Sub Cntr S�JCi Address3800 WQ 1# 4d2,ShZRy Q4f40d& Phone#�4 �6�7o7J <br /> GIS Coordinates:X Y Township Z SOu Range �a S/ Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT, OPRO ,HYDROPUNCH HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# L J",I�1I 1 Q� Q a OVER-BORE. DIAMETER <br /> 0 SELL# Q PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS:f_1/1crORC4Wii'.*t'}" ran;f F—? o7- D$ tZ ooll5lo M H C5 D _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE~ a MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: N_A <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS_0A TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR o MUD ROTARY DEPTH OF GROUT SEAL_Td-AL DePTiUrREMIE TYPE TO BE USED: D AUGERS 1RHOSE <br /> a AIR SPARGE/OZONE; .P`USH POINT(GP or CPT)GROUT SEAL PUMPED:�Yesa No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING `� AND AUGER GROUT SPECIFICATIONS Nf -i- C2iMeM+ <br /> a OTHER: a OTHER APPROX.BORING DEPTH 5b Il BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED JV A (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 /> 1 hereby,certify that I have repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces, Rule d Re lations,and all applicable California State Laws. <br /> 'offSigned x A ,^ '/ Title/Company P��,e L� �eD SC t eh+) s S+n <br /> PrintNamc� )"1.4N1 LOW t 1= �" !0 55 Date 3/07 <br /> DEPARTMENT USE ONLY�/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: &/",/.�c DD <br /> WORK PLAN DATED: a <br /> Application Accepted By Date Issued /0-10-07 Area E� <br /> Grout Inspection By Date 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# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C� to SR# Q Z.2 <br /> C-57 ✓- WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD29-02-001 WEB _A1D?"6q 4-- <br /> 9/11/2007 w <br /> 'to I qZR f o?' <br />