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.E COPY <br /> S; Joaquin Count Ne 1 <br /> Environmental Health'De artment ��� ;1J; SITE <br /> �i 600 East Main Street, Stockton, CAP5202-3029 <br /> `LIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> JANk. <br /> 3 2008 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPER��IT%54-rUI�ES <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 /> 51-{-E t ` .r^ �T . r Assessors G �T <br /> W�EE�Location�lg 1V �1 UnfT E R s� Cross Street r�� City SlVCl.'OK.i Zip Parcel# (.AJ- <br /> oFF-5 tTC- <br /> PROPERTY �v ELLS) <br /> Owner GIT G Address �O�J ►J• EL DORADO City DGKTotJ Zip Phone 2(79 9 <br /> 6nK.a SPEcre uM) <br /> C-57 ContractorfeErtsw 5bM?L4,JG Address 236o5 VJ((!s i/AM CitySZip Lic#(9363811 Phone# 4(o5-6'-12 <br /> C,ns,lta /Sub Cntr��N� lx fAddresss ilei l✓. A ltuy(A L CityFRESt-j( Lic# Phone# 559 2 L(.-253rj <br /> GIS Coordinates:X ,Y %/ Z( Township Range Section <br /> W K TO BEP FORMED: <br /> JEW WEL BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> IL BORING# 0 OVER-BORE. DIAMETER <br /> ELL# 1,AW-'SIS..&ud ! to`& CL0GQ�i] 0 PRESSURE GROUT <br /> 0*Others GROUT SPECIFICATIONS <br /> MENTS: (17Y nJ Ac 140, ,1 P&emir i ill + -- * 5EE ATKACI-IED 1✓ AP r-, . L Cr-5, <br /> TY OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS t� <br /> ONITORING OLLOW STEM DIA. OF BOREHOLE 11 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:�_ .__. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNEss-5G- 1 4-0 TYPE OF CASING: 0 STEEL b<<C 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Yee fajjo TREMIE TYPE TO BE USED: 5<1GERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes $dfo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS *'Ie'a/+ Ge V.,e ri <br /> 0 OTHER 0 OTHER APPROX. BORING DEPTHSt!e_ �t✓t,t� tA- KLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Lt f l CONDU TOR SING PROPOSED—�— --_(if YES, list spe ificattions in comment section) <br /> COMMENTS: ��eC FCle �GTTQGLI ) �f7r f r\cctV1Cell2X fide ) �eI <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I h e Mepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Ffulesjn egulations, and all applicable California State Laws. <br /> �i"r,[CtfvA (. oLo IST' Gt'O <br /> Signed x Title/Company 1�-+ <br /> Print Name k I t(( a m V i pe5 Date � '�— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Al <br /> WORK PLAN DATED: aa <br /> Application AcceptedBy4z)�Al Date Issued �t Area U <br /> Grout Inspection By j' DQ Final Inspection By to 3 <br /> Destruction Inspection By �Dte woo <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT R D REC'D BY TE PERMIT/SERVICE REQUEST# INVOICE <br /> 650 t <br /> C-57 WC=WAIVER_ C-57 Letter of Authorizr&4 to sign permit_ Encroachy neent doc <br /> I'ItD 29-02-001 W � <br /> EB � <br /> 9/11/2007 <br />