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FELE$an Joaquin County <br /> - COPY <br /> Environmental Health Department SITE <br /> 4 <br /> 600 East Main Street, Stockton,CA 95202-3029 TE <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov-org/ehd MITIGATION <br /> . UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Df r - uJD, 'PA III <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 31115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELLLocation 015/ fO C 4/e(rfr 4yew Cross Street_! rAelfi city Zip C Peressssors l r3-a3^ao6/ao> <br /> PROPERTY a <br /> Owner6<. ©vt 10044rsAddressW<LeA �_ ys Do/- 3 y <br /> wGiN 9 tfCYs-Zi S'a6lr Ph0 <br /> C-57 Contractor 6 eels Sa .�fL,�gddress dib S' W .tla city, fv ZiPj Pollic#6 363 TPhone#dOy AIGS•-yr 7! <br /> ConsuhaM/Sub Cntr fila Sewell (.•. AddressalM/Y /'f inew•Jf w CltY-k1 rJ V-Liar r Phone# -T0 d 0 <br /> GIS Coordinates:X 3'f• 1(O o ,Y —1 Z1.7-s' Township Range Section <br /> WORK TO BE PERFORMED, <br /> g NEW WELL/BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) /jiLD UCTION (choose type below) <br /> 0 WELL# <br /> 0 SOIL BORING# 7 VER-BORE. DIAMETER <br /> 0.Other {.?FR <br /> SURE GROUT - <br /> ROUT OUTSPECIFICATIONS <br /> COMMENTS: /vl W- <br /> VJ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS .+.. <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE-_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS - TYPE OF CASING: 0 STEEL 0 PVC g OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: g AUGERS g HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ONO (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> g SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS {r <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH '( g BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 'f (if YES,list specifications in commentsection) <br /> COMMENTS: ) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. E <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. f <br /> ii <br /> the I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Cou7Nam <br /> Rules and Regulations,and all applicable California S Laws. <br /> SignTitle/Company t Print Date UI i.0 10 <br /> DEPARTMENT USE ONLY f` 2 j <br /> SITE MAP IN UNIT IV FILE,ADDRESS: N- u--2 /i <br /> WORK PLAN DATED: 20:o `-- j <br /> a <br /> Application Accepted BY Date Issued Area <br /> Grout Inspection BY Date Final Inspection BY d 7, 1 t O <br /> Destruction Inspection By Date 74-16 <br /> •r <br /> COMMENTS/CONDITIONS: 9 <br /> ACCOUNTINGONLY: AID# FAC# ' <br /> PE CODES FEE INFO11 <br /> AMOUNTREMITTED CHECKS RECD BY DATE PERMIT/SERVICE REQUEST# .INVOICE <br /> 21 <br /> 2— <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permitEDoceaehrmt doC_ <br /> EHD 29-02-001 WEBdee <br /> FILE <br /> 9/11/2007 - _ .�.�`^'•,^ <br /> FI OPY <br />