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San Joaquin C' unty ROMEO- <br /> Environmental <br /> O EOEnvironmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floc Stockton,CA 9s2o�EB 4 1 2007 I!lIIT1GAT10W <br /> (209)468-3449 Fax:(209)468-3433 MIS <br /> www.sjgov UNIT IV <br /> 'I /�ONMENt HEAI1'i-1 <br /> acs `'� well Permit Appy cation PERMIT/SERVICES <br /> NON-REFUNDABLE PP.RMT EXPIRES i Y AR FROU DAVE ISSUED <br /> Appkawn is hereby made to San Joaquin County for a permit to conshuct arxilb, install the work described. This aWhcatlon Is made in oompllanee with Sen <br /> Joaquin County oevebpnmt TMe,Chapter 9-1115.3 and the StW Wards of San J mquin County EnvirwMnerrlal Heal9r Depaiknent <br /> ��I� c�!<� c.,w�1 C 4'l✓19L�tl'Q! d L'04.1l'e Kh--, Assessom <br /> WELL Locetlon I 6 CC J5. t lAF-L N t� i't`> Cross Street J `.>"_ej5-T" City y.�Tt�'lz:>P Tp `15 3-3�%Paroel/ N�, <br /> 'i l_ <br /> PROPERTY ,� q t elf Lit--k. 3�.� 1-6�j n Z li>.yh V'C.Q -7 13.5 <br /> Address I-iN-alKOF pp,-J,53-3c)Pho 2091 <br /> T ()Rrtt6NG. !►1,ald'1� rec -fhi+acs.+dot <br /> 3 �ji3Lz <br /> C-67 Conhactor P <br /> y�,NY,rriz Pala *32`1 SO $.S ]'S�` <br /> CorrsrilEsnt/Su6Cr&,.-V PcMePpt)Tl�lnlla�kAddnws 7-77`1 cAaI4 GaLCa Cdyc'c�ontA Lick 714"3q3 b3G^3 <br /> GIS Coordinatbs:X ,YTownship �, Range Section <br /> WORK TO BE PEREMED' <br /> I <br /> 9 NEW WELL/BORING (CPT,GEOPROBE.HYOROPUNCH,HAND-AODM O ) 0 DESTRUCTMN (awose hype below) <br /> 11 SOIL BORIMM fi. a OYER-BORE. DIAMETER <br /> O WELL <br /> # ,n uD 3 M �W C. ill A) I Lf�� t�5'T W I`{t3 13 PRESSURE <br /> GROUT UREEC1GFlCA�TT <br /> COMMENTS: - <br /> TYPE OF Y&Lt MFAI l nQM TYPE CONS SP IEMUgM - 5E E, w41��L, D i A�j r-A&As <br /> 11 MONITORING 0 HOLLOW STEAL DIA.OF BOREHOLE " 11 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: _ <br /> W EXTRACTION 0 AIR f W (DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL p PVC p OTHER: <br /> 11 VAPOR a MUD ROTARY DEPTH OF GROUP _ S TREMiE TYPE TO BE USED: 0 AUGERS U HOSE <br /> a AIR SPARGE!OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUM 0 Yes 0 No (NOTE:C*M=UP FREEALL DEPTH IS 30') <br /> E SOIL BORING Q HAND AUGER GROUT SPEGWI+CATIONS one-fI'I&m-t !! e-` <br /> 1)pTHER D OTHER APPROX.BORING DE1 fH S r Q�BDLTwn TRAFFta BOX W a STOVE PIPE <br /> CONDUCTOR CASINGj (if YES.ust spedtications in 000unent sedion) <br /> COENTS: - - _-- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS:'AGREEMENT OR ENCROACHMENT PERVM. <br /> 48 WORKING HOURS NOTICE QWRED FOR INSPECTIONS. <br /> I tomW certify that 1 have prepared this applicationand ;the work rorip be done in accordartce with San Joaquin <br /> County Ord na es, les and Regtdatlorls,and all applica Cali[m»la Sime Laws. FNVIQoN Nil-Ni-A i- <br /> X '� �' parry c.�i=-h1t�F= Ei�tc�it�[ir��. ,�R�MEDiATicN GAP-�Ui <br /> Print Name �k-Yr CF-7rEN taale /ic�t 7 <br /> DEPARMEIT USE ONLY <br /> SITE 11111AP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date issued--,a2 v Area C,Apply <br /> Grout ImPaftn Accepted By. , r v Final Inspection By o Dam 3 ! <br /> Grout Inspedion By`�'�• �� UDestruction Inspection B^ Date <br /> commNTS i co"Orl U*IS <br /> ACCOUNTING ONLY: AWM F':ZW <br /> PE CODES FEEIrTfO AC�WlNTR[LX71ED CHECKtt GID By DATE PER=lSERVICEREQUM* INVOICE <br /> 3��3 � s :3'1I-! -70'1- : of+� SFW gj123 <br /> C-57 WC -WAIVER_„_ C-57 letter of Authoriza ion to sign pertllit_Encroachment doc <br /> ERD 29-02-001 <br /> G22roo <br />