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P EG NEO <br /> z aUrM .a San Joaquin County <br /> Environmental Health Department PpK ' 3 -�ppa <br /> N . p Gold SITE <br /> X <br /> 600 East Main Street, Stockton,GA 95202-3029 JOpOU1M�NtNMITIGATION <br /> v (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.or�j1N�ppPSM� UNIT IV <br /> Well Permit Application N <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 /> R.WxAssessors <br /> WELLLocation I9$�5 W�(.,e rl.� R1.• Cross Street T.r lc rwev City al Zip 95391 Parcel# 209-04O-31 <br /> 9300 W' L �"i roo-Lf3 <br /> PROPERTY <br /> Owner C6KL((ee.:l.f ikvetepyyuw'f Address 11214rp6AA(w.4.y91e145..:k.�City h4 Lv&r Zip 95(70 Phone# <br /> C-57Contraclor Jiw Df.lie"T4w- Address f•O.Bor 970 City-14 Zip95241 Lic#7�Phone#709-347-9#oo <br /> Consultant/Sub Cntilrl(ua-(e.irlrAlfec;.fef L"Address3gle 0.0ee..-.Lee.5.44city 1}1dc4ew Lic# Phone# 2o9-21g-7722• <br /> GIS Coordinates:X 'Y ,Township 25 Range 4 E Section lla <br /> WORK TO BE PERFORMED: 1. <br /> E NpW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 11 DESTRUCTION (choose type below) <br /> ff��SOIL BORING# �-a OVER-BORE. DIAMETER <br /> �Jp/ELL# 'PRESSURE GROUT y <br /> I(a'Other GROUT SPECIFICATIONS Mfa� Ge.1.1w1 <br /> COMMENTW <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING OLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2� <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 1,k.00 TYPE OF CASING: a STEEL 4 PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL.KV (L l 115 r TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Nlf-1- <br /> a OTHER:_G OTHER APPROX.BORING DEPTH 3or o'1 41 r a BOLTED TRAFFIC BOX or ASTOVE PIPE <br /> * I CONDUCTOR CASING PROPOSED (if YES,list specifications in comm�ern/t�section) <br /> COMMENTS: D�•S"TLC L-�'7. Dv� ✓�W I'3 :;01-T­-L1 en W 4 co O r t--t'� <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 Ord-nanc/ees,, yule an Regulations, and all applicable California State Laws. 1 V <br /> Signetlx `�I ,f'/ - - fA rr Title/Company Sr 5_ _11.4 ...e�l, /�/WMlace-l.. i1ASsec. <br /> Print Name Mirk ICe n+�W0.51�.�r+n Date t ZAS, <br /> DEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S <br /> WORK PLAN DATED: <br /> �—,t , / / q <br /> Application Accepted By / n' `� < Date Issued T Area (O O y <br /> Grout Inspection By Date Final I paction By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � <br /> °l0'6 1 6 0 A 60 5.13 D( (__ ?'14 IqN UW SR#3 3 � �3 <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 />