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05x'29/2008 13:37 7073745677 WOODWARD YARD PAGE 02/04 <br /> FRE C E,�VIEf,ED <br /> - . MAY 3 0 2008 San. Joaquin County <br /> t�LV #.Ruf`�lv1ENT EiAp-jronrnental Health Department SITE <br /> ast Main Street, Stockton, CA 95202-3029 <br /> '�RMIT/SER', MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www_sjgov,org/chd UNIT IV <br /> r6�' ' Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work dearribed. This application is made in compliance with San <br /> Joaquin County De-elopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ASSMSOM <br /> WELL Location � Sbu}r) 54C(Q 1P6ju S4CrossStreetsfCyk? _City LD4� Zip g5a41DPa l# 046 8a()0(C, <br /> PROPE TY . � <br /> owner_ Acw1rie 6ws and EA-1 /rAddreaa31 Seale S{ _Cay rm ` celMDQS Pnon.#'JL q�3-9654 <br /> C-37 Contracior(�,dAOafd �r,Brno Add�+resrS O kr yer Rb-dmm_Gity O ( 2Zip915L I Licit 007f'I honeg 0 ��(/"4,200 <br /> Consultant/Sub Cntrs+,I ift?ry l0(rner� JfEdruss57 Lxhckyphle 61re� city l Lidf_._ _ Phon®#�c�5-c3`��"`�'OC7 <br /> GIS Coordinates:X_ Y Township Rahe <br /> g ( ET,W Section <br /> WORK T9 E PERFORMED! <br /> NEW WELL I BORIN© CPT.GEOPROBE.HYDROPUNCH.HAND-AUGER.OTHER') U DESTRUCTION (choose type below) <br /> #SOIL BORING# ---:)-7 _ a OVER-BORE, UTAME I ER <br /> WELL fi_ 0 PRESSURE GROUT <br /> Q'Othor GROUT SPECIFICATIONS <br /> COMMENTS /(o SO1j b0ftYldl -fair_, j ,ictrr,p� f a J! Sctn,n _bnr;,r,ns �iif g Sar, l�s. <br /> TYPE OF WELL INSTALLATION TYPE CONSI�jI1CTION SPEGIFICATtONS <br /> p MONITORING p HOLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> U EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: (I STEEL 0 PVC U OTHER: <br /> -VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE; MAXIMUM FREE'-FALL DEPTH IS 30') <br /> SOIL BORING U HAND AUGER GROUT SPECIFICATIONS _ <br /> Q OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> J CONDUCTOR CASING PROPOSED _ (if YES,list speciporatione in comment gaol on <br /> COMMENTS, OI �Dft/1pl7DC S6(1 , jgx 4,vlh A, 11 bp- a�irtii4J^ Ix'r/na:,r...:kr da Or S <br /> 0o_ <br /> — �— P 41e-t wt t <br /> ioe, -V 49sj bor' Or yrOu ,-Voda( ha <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 /> Signed zC 1?LQ�•t _ Title/Company Pr } <br /> Print Nam. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD? SS: 7 t <br /> WORK PLAN DATED: // p DO _ <br /> Application Accepted By ,�/�,,,n.i}C�( ^_ Date Issued 64ola Area. Q9, <br /> Grout Inspection By „Date Final Inspection By Date <br /> Psstrvction Inspection By Date <br /> COMMENTS/CONDITIONS! <br /> ACCOUNTING ONLY; AID# FACdd <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REG'D BY DATE PERMIT/SERVICE REQUEST R INVOICE <br /> L'01 ffQ ,9 �t� D� 5R# 905 -YAe)7 <br /> C-57„_, WC_-WAIVER, C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> FHD 292-o0I WEB <br /> 9111/2007 <br />