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opo ' ": ..jan Joaquin County <br /> InSI <br /> q <br /> Q `� Environmental Health Department SITE <br /> 600 East Main Street, Stockton CA 95202-3029 APR - 1 200MITIGATION <br /> I , (209) 468-3449 Fax: (209) 468-3433 Web : www.sjgov.org/ehd LTYNIT IV <br /> �. ��• ENb ! ONIOEPI � HEN <br /> RN` Well PermitA lication HRVItCES <br /> Application PERMI7, � <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 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 /> Assessors <br /> WELLLocation 51 '7 WPsF 6 MW SWL Cross Street yEljjjnnnM sv...+- City .wenn «,,, Zip 4;2oa Parcel# 131 - ym- io <br /> PROPERTY <br /> Owner 11f /luc.� Address .5ii iuiol cwwm rlrzf City ..hxLbn Zip9S2w Phone# 222 4 � 9y �v <br /> dudr1 farshue F'ehPan <br /> C-57Contractor Hileku Drulm, Emr,mnunia/ Address 74mo /+: lu 11wnia City Bt, reka Zip 95Y03 Lic# 679Ur� Phone# 707- jVy - Ya <br /> Consultant / Sub Cntrlldoenrrd 11rn F7n.mna,a,r.L ins Address aa-i shnw Carr,! City 3k1klan Lic# ftovn7 Phone# aow-ebrlmU <br /> GIs Coordinates: X., Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> jj. NEW WELL / BORING (CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING # a OVER-BORE. DIAMETER <br /> j1:WELL # 061111 W-a. OW-1, aw;� IB7n.l emy 0 PRESSURE GROUT <br /> a *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING *. HOLLOW STEM DIA. OF BOREHOLgqF/° 4 a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: :�o <br /> `' EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS N�)A TYPE OF CASING: a STEEL tPVC a OTHER: <br /> WVAPOR a MUD ROTARY DEPTH OF GROUT SEAL Wh4 2 I&V TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE) OZONE PUSH POINT (GP or CPT) GROUT SEAL PUMPED: a Yes a No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS type T_/ a Portland N Oa+al 0+mad <br /> 1TOTHER: 01r;nvnhto Q OTHER APPROX. BORING DEPTH 35 'bsy. # 15 %5q, $ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED win (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMiak <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 Joaq <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws, <br /> Signedx _ ? Title/Company Vfte DiesidmIF /Adupmvd 6raLnwwmrn4A0. Inc <br /> Print Name y?Z - `(7PK1 6 N - v1oL Date 01 I3 v; 1 10 <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE, ADDRESS : ski U . <br /> WORK PLAN DATED :: A 101 o'�' ( ytj' t e Vt� t I 'o 1261 01 ( on I ors -2 t nw• 1 nw 1 <br /> Application Accepted By - 1 _.. iml _ , Date Issued L 4- 10 Area <br /> Grout Inspection By 1 ,� Date c( 1 + 1 O� Final Inspection By Date 4is O <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 SERVICE REQUEST # INVOICE <br /> 5ftr ON3 2q4 0J 3 g7i• DJ Z X05 4 1 y�0& SR# 53-1-S � <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />