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#1FOR <br /> San Joaquin Countyn������LEnvironmental Health Depart � SITE <br /> 600 E.Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgovSVetld 8 2007 UNIT IV <br /> Well Permit Application ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEPi bT/SERVICES <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> n ` Assessors <br /> ^ <br /> WELL Location a 440o E.TImd AQod Cross Street EScalch City rL Zip I SoT3Fi Parcel# 093- C�-dam <br /> PROPERTY (esdu) r-� � <br /> Owner QaorT.c Gia5 4 dere,,r ro. Address 3 0o City�pg�_Zip 94583 Phone#(gas)8b6-5�g- <br /> �oomµI38' <br /> C-57 Contractor Preunen Sa,,.nlln Address laki e_mx c A.ie . City Zip _Lic#SSS*Phone# 5jao 83 - 75-- <br /> 19470 N.Ca447;n Pit <br /> Consultant Sub CntrTnrr eixa rCl�4?__Address Sdi S'3oily filar... +�+ic# '— Phone# (92s)als-V&1 <br /> GIS Coordinates:X I 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ffiEW WELL f BORING sCPT GEOPRO YDROPUNCH, AND-AUGE OTHER") 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 6 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> n"Other 1 GROUT SPECIFICATIONS <br /> COMMENTS:' b4 Q, .�} \.,S <br /> 7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> u VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )KSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: OTHER Sow ALAR- APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: AIN � r cI S1l, S <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 Ordinan/C / <br /> as, RulAles a d Regulations,and all applicable California State Laws. <br /> Signed x� v Title mp�ny TErra j'nr t•. lD <br /> Print Name - Dale <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2AA0i> E- 6� <br /> WORK PLAN DATED:/AI 1�r. ,de - 7,r�p'1 <br /> Application Accepted By Date Issued C1-z I l V-'L Area 3.( 1It <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 7Ad,N 90j.0v 19R,0�? L--�'SI o( tit SR#UC>5201AD <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-00I web <br /> 6/22/04 <br />