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COPY <br /> �} �i <br /> San Joaquin County ti cI�L7 L` lit` <br /> Environmental Health Department - SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 OCT _ 4 2007 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov. >s , <br /> t ?�,�I4r1 V1 r1 ATL UNIT IV <br /> Qx{. Well Permit Application ='P1 P0jT/FRVjf I f <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 /> ' Q Q t Assessors <br /> WELL Location 11110 1.V/ •�Y(dn ^p Da4 Cross Street rkkICA City� p_Zip �I S✓0l Parcel# ZOO{^/SO^ y <br /> PROPER <br /> TY r /� <br /> Owner 1 0fi4li r_&s+elr' _Address a171Q0 W I3n VrDn Cjd City faC Zip gS30 'hone# ZOq 833,95507 <br /> C-57 Contractor RS I �DAr;I/^'1)�C� Address �20�p�� CaST St City A/Ikip 3 7 ic#80233%hone# O 2g2y <br /> Consultant/Sub Cntr (l ACddress 70 0�Q�tAye�SkU6Ry �r*.Aq(�k Phone# 6 Y1(e' 07.5 <br /> GIS Coordinates:X 31.77(,Y-IZ.�. 7L1 Township2— SORA Range / Gas Section 10 <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING SpP� )DROPUNCH,HAND AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# F �� a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other _ GROUT SPECIFICATIONS <br /> COMMENTS: SlLL r_ cceS$ "yfZeW►CK+ Q GIC <br /> TYPE OF:WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:,r�A _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS A TYPE OF CASING: a STEEL a PVC a OTHER: /V A <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL O'FAl 7>iA TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE ,VUSH POINT(GP or CPT)GROUT SEAL PUMPED: )KY``e''s,A, Noo (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS / � UwieNt <br /> B OTHER: a OTHER APPROX.BORING DEPTH r�� a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (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 Ordies, Rules Regu ions,and all applicable California State Laws. <br /> Signed x_ A /, Title/CompanyroSC�levl'� <br /> Print Name I L-LIA LDUI fn (52N39-7665Date zd33/6-7 <br /> DEPARTMENT USE ONLY �cl;6D <br /> SITE MAP IN UNIT IV FILE,ADDRESS: A � �'tA4 / �o <br /> WORK PLAN DATED: O <br /> Application Accepted By �4� Date Issued ���! O T Area O�p <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 /> M01 %]5l s q Grp to SR# 052.Z`�(P <br /> C-57 y_ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit_Encrog�nt doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />