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a � <br /> San Joaquin County a E"C, AL <br /> Environmental Health Departmen SITE <br /> 600 East Main Street, Stockton, <br /> CA 95202-302YCT _ 4 2007 MITIGATION <br /> 1 (209)468-3449 Fax: (209)468-3433 Web: www.sjggjVTp/(94'1FN t HEALTH UNIT IV <br /> X f � Well Permit Application E'EN [�1 �'),-R ICES <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 /> n I� Assessors <br /> WELL Location 17200 W. Byfoo► a Cross Street kK ur1 City C Zip r o1Parcel# 209-1;5'02,3 <br /> OwnerPROPITY r Address/V0 w 13 ron R , p <br /> Owner {/na 3p�.i 5,5 ,r' Cr l City 11701C/ ZipjEMPhone# Z0 1 ^OSS 7 <br /> C-57 Contractor hJ 1 AD Ill1�)C� Address 2-20 1N•Eotsf t city WW 1#nJ'p 577:Lic#gG231Phone# 1 �o -2ele? <br /> Consultant/Sub Cnttrr A IC AddressRoo bAl or Ste 2/06 i en 16: �''—L'� Phone#qQ [b' 0 <br /> GIS Coordinates:X *,T7-1 Y 12- .52-3 Township � SO Range T 66..5 Section <br /> WORK TO BE PERFORMED: <br /> >0EW WELL/BORING (CPT, EOPR DROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> ; $OIL BORING# q N a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other L GROUT SPECIFICATIONS <br /> COMMENTS: S,- <br /> lC ACCeSS ree*,%en+- 1:f CtlC <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:A A <br /> II EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0A TYPE OF CASING: a STEEL a PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEA -1► e TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> AIR SPARGE/OZONE_-ffl<USH POINT(GP or CPT)GROUT SEAL PUMPED:,;<e'es 0w-0_(N_OOTE: MAXIMU FREE-FALL DEPTH IS 30') <br /> OIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: 0 OTHER APPROX.BORING DEPTH O p 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 /> 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 Ordi ces, R I and egulations,and all applicable California State Laws. cc -}� <br /> Signed x r Title/Company Pry e_a G C0 J�) A4 ►r 5 S'q1 C— <br /> Print Name (I lQi(f/) �zo to, (d•3�-�(p55' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: „ /�-� P6 dz,Lte �'�'�0 4 AP/YIGo <br /> WORK PLAN DATED: O-,7 <br /> Application Accepted By Date Issued � � Area &6 if <br /> Grout Inspection By Iffate 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 f SERVICE REQUEST# INVOICE <br /> 2Q0 Y ISA cct tU ,5 SR# ()4! Z 2, 2- <br /> C-57 <br /> C-57WC -WAIVER_ C-57 Letter of Authorization to sign permit_En5p�ment doc_ <br /> EHD29-02-001 WEB 104 - QLei <br /> 9/11/2007 / <br />