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FILE UPI <br /> San Joaquin County <br /> Environmental Health Department Y� SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 1� MITIGATION <br /> (209)40$-3449Fax: (204)468-3433 Web:www.sjgov_org/ehct ��.�� UNIT IV <br /> Well Permit Application <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 mrk described. This application is made in compliance with San <br /> Joaquin County Deveb men/Tine,Chapter 9- 115_ and the Standards of Sun m <br /> Joaquin County Environmental Heanh Department. <br /> �j/��r^ Assest: " <br /> WELL Location /v{l gog Cross Stree_ City IZ``ip t s t Q r�PL,arcelN_ �p�./>3� 6 <br /> PROPERTY t: ^ ar Clty�f _2JipJ"7 phone#r�0�1'b2J1-4y JO` C��t' '�J <br /> Owner Address <br /> C57 Conrado' lit <br /> Cons uttant/Sub Cntry� <br /> 1"x.111_. .... ._._ _Address; Lj� N.tll !_b�11 [Citv .rC4tntJa'tZLic# wGll____ �/A! Phone#4i6- r�( (7 Cjpn�Y�Z� <br /> GIS Coordinates:X�T•TV S —1ZI. yL5 ,Tawnshlp i '7- Range _ )G Sectbn <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT,GEOPROBE,HY DROPU NCH,NAND-AUGER,OTHER') D DESTRUCTION (choose type tietaw) <br /> U SOIL BORING U OVER-BORE. DIAMETER <br /> III WELL# U PRESSURE GROUT <br /> U'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> /��'rf��QF WELL N LLATI0 TYPE CONSTRUCTION SPECIIF19AMN-3 <br /> 1 B yIONtTORING OLLOW STEM DIA.OF BOREHOLE_11 p MULTIPLE CASINGS [ MULTI-LEVEL WELL CASING DLA: r�_ <br /> n EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS Gr L, CIf! TYPE OF CASING: Q STEEL p PVC 11 OTHER: <br /> U VAPOR n MUD ROTARY DEPTH OF GROUT SEAL 11 TREMIE TYPE TO BE USED: M AUGERS g HOSE <br /> a AIR SPARGE/OZONE 1)PUSH POINT(GP or CPT)GROUT SEAL PUMPED: DYes III No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING a llAND AUGER GROUT SPECIFICATIONS ?V­1 l,,,v,4 'T D <br /> a OTHER: l7 OTHER APPROX.BORING DEPTH._3'5 g BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSFD AA (if YFS,list spechicatinns in comment settion) <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 Ordin nces, Rules and Regulations,and all applicable California State Laws. <br /> Signedz '(9L� TiuelCompany—CtLILI t`11( 1i _ <br /> Pont Na1neM,1rr 1111/ r. Z'? P DatetJ2_�C._fIR <br /> DEPARTMENT USE ONL <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 39CO <br /> WORK PLAN DATED: 0e-T- ZOO <br /> Application Accepted By _Date IssuedF7"— Area <br /> Grout Inspection By 1, Date Final inspection at _ <br /> Destruction Inspection By Date <br /> COMMENTS d CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 90 M 3 I-z o8 SR# L9!53C)VA <br /> C-57 WC -WAIVER_ C-571,ette Authorization to sign permit_ Encroachment doc <br /> END29-02-Val WEB <br /> 9/17/2007 <br /> V <br />