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i�rlI- 'If11 <br /> rL <br /> N San Joaquin County ` NkI GG,�'ICtS <br /> Environmental Health Department SITE <br /> ' 600 East Main Street, Stockton,CA 95202.3029 MITIGATION <br /> (209)468-3449 Fax:(309)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construot ondlor Install the work described. Thi*application Is made In Compliance with San <br /> Joaquin County Development Tile,Chapter a-1115.3 and the Standards o1 San Joaquin County Environmentel Health Department. <br /> /^ �+/ Aseossc <br /> WELL Locadon --gsU �.� Goss Steat A7 tv City hre zip 15,W parx-ril n39-sd <br /> O - <br /> Owner n� Cl nr.Clty � Y ZIp95.Lo Phone$ <br /> Owner t e� rtrA Address Alt) <br /> G67 Cuntracto, 11)DL/'-c Add(ess DA00 kel•/.A VP <br /> Coneultantl Sub Cnn7- JnuiY¢ �n�r/� Address .` .��-�V M /fa/Cltyf/,1 I�cu X58/'�3 Phoned g7�,.7!/y-Z?a5-/i <br /> 015 Coordinates:X Y Township Range Section <br /> """-W���,�0-�,,--RK TO RE PERFORMED; <br /> "�EW WELL I BORING (CPT.GEOPROBE,HYDROPUNCK HAND-AUGER,OWER') Q DESTRUCTION (choose type below) <br /> 0 SOIL BORING$ Q OVER-BORE. DIAMETER <br /> ;'WELL$ Tf1 aPRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> E OF WEL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHl R MULTIPLE CASINGS Q MULTFLEVEL WELLCASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS S'r.I. UA TYPE OF CASING: Q STEEL )<PVC Q OTHER: <br /> _.-.11 VAPOR 0MUO ROTARY DEPTH OF GROUT SEAL_(-t�_-._7REMIE TYPE 70 BE USED: 0AUGERS ,�iOSE <br /> j AIR SPARGE OZONE Q PUSH P0114T(GP w CPT)GP.OUT SEAL PUMPED: RYeS ONO NOTE:MAXIMU11M FREE-FALL DEPTH IS J0 I <br /> Q SOIL BORING nHAND AUGER GROUT5PECIFGATIONS Feline mrn�tiTr I.J(Yk 69 hvvr4- at,4c i <br /> p OTHER:_�_�O7HER Sin 1G APPROX.BORING DEPTH 9_11Oy J U BOLTED TRAFFIC BOX or ,(STOVE PIPE <br /> CONDUCT OR CASING PROPOSED nn (if YES.IM spetMcatlons 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 prepajoad this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Rul and 09glations,and all applicable California State Laws. <br /> Count `•.—. JJ TitlalCompany c.77rC/7' /r o���d/)k XS/T r_� <br /> Print Name-5i/�� <br /> DEPARTMENT USE ONLY 1 7 <br /> SITE MAP IN UNIT IV FILE,ADDRES: 5 C + <br /> s .� <br /> �. <br /> WORK PLAN DATED: �is C' <br /> y _—_,Date IssuadA I 0 T1 o Area w <br /> ApPllCatlon Accepted 0 <br /> v <br /> Grain Inspection By 1 \��ti ew Date 4 Z2 b5f Final Inspacdon By at Date 6MAIC <br /> Destruction Inspection By oats <br /> COMMENTS ICONDR1 l <br /> ACCOUNTING ONLY: AID! FAG$ <br /> pE CODES FEEINFO AMOUNTREMITTED CHECK$ RECD BY DATE PERMIT/SERVICERrCUEST$ INVOICE <br /> C•57_,,, WC___-;WAIVER— C-57 Letter of AUThariZatian to sign permit_Encroachment doc— <br /> EHn 29-01.001.WEB <br /> 9/11/2007 <br /> Z0 39.".d 991 696Zb069M LT:bT 000Z(TE/E0 <br />