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�o San Joaquin County (o� <br /> Environmental Health Departmen L� �aL� u V <br /> ° SITE <br /> " 600 East Main Street, Stockton, CA 95202-3029 ULL 0 7 2007MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> • '` QR`' Well Permit Application ENVIRONMENT HEALTH <br /> SER <br /> PERMIT <br /> / VICES <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 /> 1 Assessors <br /> 6 <br /> WELL Location Z06'0 , FRF+MOA17 S7 Cross Street W fl 7l'SS <br /> - City . Tcr.KTbd Zip Parcel# 15313 - OOS <br /> PROPERTY a� <br /> Owner SILL + 146—tiy SIDE RNERAddress 7015 MCA70Al COUA7 City S ?nClcTo/J Zip SdXl9 Phone* llJ. 5-r73 <br /> C-57 Contractor r RC-C% DIQI�I A/G Address 7.515 1/01.JC- RDq)� AT <br /> City NEZZip/ Yg3Lic# $ )bSSPhone#9�2S3l.ZS:Gt7 <br /> Consultant / Sub Cntr f)7G llsSoclArES Address 107 LOnIeT P44M AV. CityFIoDESTo Lill Phone# .r94s ;O" <br /> GIS Coordinates: X., Y Township Range Section <br /> NwkO BE PERFORMED: <br /> WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) D DESTRUCTION (choose type below) <br /> D SOIL BORING # D OVER-BORE. DIAMETER <br /> D WELL #_M W I G -- MW 19 D PRESSURE GROUT <br /> D *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING p''// ' r <br /> nOLLOW STEM DIA. OF BOREHOLE LO +r D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS SCN YO TYPE OF CASING: D STEEL 015VC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 97 + Fit ' TREMIE TYPE TO BE USED: GAUGERS a HOSE N <br /> D AIR SPARGE) OZONE D PUSH POINT (GP or CPT) GROUT SEAL PUMPED: "s D No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') Q <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER:_0 OTHER APPROX. BORING DEPTH 60 #4a 9O ' OLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED dO (if YES, list specifications in comment section) r1 <br /> COMMENTS: oCGr6A +4TCS 5%l6rdAZAcG. /NV/C TS , A7ia�l h/o.CKl�tA+✓ DATEI <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS . <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. (r <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 hd �gulations, and all applicable California State Laws. <br /> M1 <br /> Signed �r- it/Y--' Title/Company x+57 47i=e WS60toes <br /> Print Name /o-b.b W 's C—x Date Z o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : o` MS �lvvxo ,J� SA . I <br /> WORK PLAN DATED : in 119 2- ( 6 <br /> Application Accepted By[A�OAAA42L�\ Date Issued 1Z 11 O fO Area Z t <br /> Grout Inspection By lh�AA^A c.n. Date l o Final Inspection By Date t I c r I n i <br /> Destruction Inspection By Date �T�— 1 <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 /> SR# S 2 `6KS' <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 f <br />