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fl- - LE COPY <br /> ,o:• �o l4an Joaquin County ( r �\j <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 JUS! 0 3 200MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> P ENS/IRQNNIFNi NEALTUNIT IV <br /> Well Permit Application PERMI'USER'' IEE" <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 /> WELL Location • IOU -e. &� Dross Street tj-MAL ARTMM&IkC R Assessors <br /> ity _Zip9537� Parcel# 2•50-7.2o-08 <br /> PROPERTY /Ja `f R v�o_ �' `/ <br /> Owner I GCE Address/' /j 7y CRY l�' •, Zip2�}�Phone# Zo1 94t-IS7o <br /> C-57 Contractor 0J 1,a-)�A PA�)(i'J'1 Address S� RlVy aogn CityYroTTV1$t4 Zip '1S7l Lic#'71"71 Phone# o7) 37y-g3ao <br /> Consultant/Sub CntrIrso Nps. lA[ddress /oo W, w^lw.r S;. City PAsna�Lic# Phone# �OZC u/ a-b0G7 <br /> GIS Coordinates:X -1 o ,y 42.4 ]/Des ,Township 'Z• SO1 LRange J` 6A•S7- Section Z T•• <br /> WORK TO BE PERFORMED: <br /> MT. D,a161• PAawwrL MFAIO a� <br /> KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGEROTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# A 3-2- a OVER-BORE. DIAMETER, <br /> WELL# -•S a PRESSURE GROUT <br /> Other I GROUT SPECIFICATIONS <br /> COMM NTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `KMONITORINGO a-HOLLOW STEM DIA.OF BOREHOLE I2. 9 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: GI__ <br /> a EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS Sok• LI0 TYPE OF CASING: a STEEL )(PVC n OTHER: <br /> )(VAPOR (IS-) a MUD ROTARY DEPTH OF GROUT SEAL 0-3 �+ TREMIE TYPE TO BE USED: XAUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING(13) aHAND AUGER GROUT SPECIFICATIONS 13A•-fb"ra. GtiPS <br /> D <br /> OTHER:_a OTHER APPROX.BORING DEPTH Z6 44• BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> - CONDUCTOR CASING PROPOSED IDA (if YES,list specifications in comment section) <br /> COMMENTS: J�-� �}TMcµ� /7i P.S_A WA-l.( C� P(.-f�' J MAyt4 <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed '�•-IG�^-+� �. �F+1'„`-` _ Title/Company �ti1Nc%r,l Geo1u�,57- Z/p <br /> �rSJNy <br /> T <br /> Print Name ! 1 I o&\A 5 '1'• L A,,j& Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �L E <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date, Final Inspection By Date <br /> Destruction Inspection By Dale <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 /> �0� 6 (• 3 SR# <br /> G A: 105 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign Permit_ Encroachment doc /V <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />