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San Joaquin County lopy <br /> Environmental Health Departmen�EP 14 2007 <br /> 304 East Weber Avenue,3rd Floor,Stockton,C SITE <br /> AE?AMINVIENT HEALTH WITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov. hT/'ERV!CE <br /> Well Permit Application UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L,,7 I y�L� <br /> Application is hereby made to San Joaquin County for a <br /> Joaquin County Development Title,Chapter 9-1115.3 and the lStand ds of San t to construct JJo Joaor quin unthe ty work <br /> meental This <br /> hDepartmentade in compliance with San <br /> WELL Location 5F aj, g�Urj (�U� tip �( <br /> PROPERTY// /1v,�/� Cross Street1}lit', City S Zip 15� Parcel#Assessors l� <br /> Owner �l T.r�,s Address 1 t�G1Gt�`f <br /> _Zip 12Z-5 Phone# <br /> C-37 Contractor e p�1i -�'I, Address dolt) -.---}- j �`�'J, �i <br /> t- -�"" v 3� CityWOO) Zip�f511 U �Z Phone#E 3'G}fid' 11Z y <br /> Consultant J Sub Cntr��iu (' i5(��z <br /> p�C✓IvIlalNul> "rt�t Address_ tu»�dU'I (y CPty uvN1', C <br /> GIS Coordinates:X-31. -7(0 Y- 121.33(0 —_Pnone# 53r?-(s 7(_,2v�Z <br /> Township � Range. �}; <br /> W R Section <br /> P RF p; <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') <br /> Q SOIL BORIN # p DESTRUCTION (choose type below) <br /> ,� <br /> -`OtherLL#r 'ww ���1 V 0 PRESSURE 11 , DIAMETER <br /> COMMENTS: <br /> GROUT SPECIFICATIONS <br /> E Qf MLL INSTALLATION TYPE CONSTRUCTIONffWSPECIFICATIONS <br /> ONITORING HOLLOW STEM DIA.OF BOREHOLE . I' 11 <br /> !1 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:� <br /> p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSS <br /> Q VAPOR �_TYPE OF CASING. Q STEEL `f�PVC U OTHER: <br /> Q MUD ROTARY DEPTH OF GROUT SEAL -3' TREMIE TYPE TO BE USED: 0 AUGERS <br /> HOSE <br /> o AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes o (NO E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING p HAND AUGER GROUT SPECIFICATIONS R (.�'M�n <br /> Q OTHER: n OTHER APPROX.BORING DEPTH_ZS J <br /> ]'};BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED AD (if YES,list specifications In comment section) <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 /> pry/ ~~ <br /> Signed x t�v" � 1/--\r Title/Company 6 3q <br /> j Eo U, <br /> 1� (� �11:P.K•tkl' ,�c� <br /> Print Name �it + q�i �;n�.rf Date 13-v <br /> DEPARTMENT USE ONLY b- LOPSITE MAP IN UNIT IV FILE,ADDRESS: #�j <br /> WORK PLAN DATED: p <br /> Application Accepted By Date Issued-01110414Q 114�— <br /> Area <br /> Grout Inspection By Date Final InspectionDate Ld <br /> Destruction Inspection By Da e <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID#t FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC=-WAIVER___,- C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29A2-00I <br /> 6122/04 <br /> O&IVo7-6Sr/—o 6� <br />