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an Joaquin County <br /> i � tvirlomental Health Department SITE <br /> �� ast Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> t Fay u-i 13 2007 Well Permit Application <br /> ENVIRQNN ENTFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PERt�11TlERt rcLV <br /> Application is hereby ma a to an 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 /> WELL Location S. S9CK 7oN6 RD. Cross Street E.14A R/PoSA " City S7b c/c7oA/ Zip `}5111111111111113- Parcel# <br /> `JS 2/—s- <br /> PROPERTY <br /> - <br /> PROPERTY <br /> Owner C/ANNECCN/N/ comPANY Address 34S/N. J.-4cK 7y NF 20 CityS2ocK ,y Zip 95'2/3- Phone# Z09-93/-3VS2. <br /> C-57 Contractor-ASL DR/cc/NC Address ZZ,0 N. E4s7-ST. City Wooa41ND Zip 9539! Lic#80233V Phone#s3o- 668-2-92Y <br /> 7F)ZA4C m �NSucTAArrS 790, 6AucEE AD, <br /> Consultant Sub Cntr /N<. Address 5W 17F kL a City Aos¢v/c F Lir# Phone# 9l6-98Y-2283 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# All /B B OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS:10 GeaPRoBE 7v 8' 68-/7H9u 8-a 8-u, B-72) ; Z CnPR- &- 7p ii CB 9.B ion ' 3 //YDRoPUNcN 7o CW C9-3�6-L B <br /> 3 HANG 6ER Sv � HA-/ 77ARu N4-3 N°T'ru EXCEED ZSR <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Z" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE O�uF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S077DM OF aOAj I REMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE ,PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes )KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS A/FA� CEMENT A 69o4ND sURFAcE <br /> 0 OTHER:_D OTHER APPROX. BORING DEPTH S'EE AaovE 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: -.)k-IF No CW /N 8-/ TkRu B-/2 . &NE BowNC wicc BE C Arr7Nu ED-mlt4AX ZSR 7DA77FMP770 <br /> Gi,vo Gw DFPTN <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, flules and Regulations, and all applicable California State Laws. <br /> Signed Title/Company ENv/R,+NMENTAL DE�'i9F-TMEN�MA,yACFn-/7tn,cAco,J <br /> Print Name 'SAMES lcIERNAN Date <br /> DEPARTMENT USE ONLY <br /> i <br /> SITE MAP IN UNIT IV FILE, ADDRESS: :��C- <br /> WORK PLAN DATED: b' /'Z,2,06� <br /> �J- ' Gi <br /> Application Accepted By `�7?C.v�""-J ( Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: Y <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> rl ; �" IC. jcbr� /1 i/ 11� C7 SR#Z,C� <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD29-02-001 WEB <br /> ni++innm <br />