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04/28/2007 11: 57 916-786-0366 LFR PAGE 02/03 <br /> 04/30/2007 MON 10:57 FAX 20•'3433 SJC BED • 2003/003 <br /> San Joaquin County <br /> w,5. Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209).468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> L CoQ Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 compllance with San <br /> Joaquin County Development Title,Chaoter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /1,� .rs11s yAssessors <br /> WELL Location ���Y9 S/'fuaC�'rZ+`^ Ccross street W. City ih Zipp Parcel# ,.7-531 1 0 46 <br /> PROPERTYg <br /> Owner <br /> ��r ,,v,,,�_,rA�ddrless�9ff� <br /> C-57 Contractor LAO f.�t�/�'r'7/�°' ddress ��P cmwv rAmflµ4d61 Azip4.�98Lic# <br /> Consultand Sub Cntr LF�I /NG Address: i a.. RxmrAS . Cityk i Phone#90'1115.7 e3� <br /> GIS Coordinates:X __,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND•AUGER,OTHER-) >MESTRUCTION (choose type below) <br /> p SOIL BORING# Q OVER-BORE. DIAMETER <br /> O WELL# ,e0RESSURE GROUT , <br /> 0"Other YGROUT SPECIFICATIONS 0'I/Z/����' S <br /> COMMENTS: d7 77JOr /}7Gc! S — �.t/2? • 9 MI)S y�.�+ cow CaD St, 0q,44.d9 'C-.. <br /> NR77 <br /> TYPE OF WELL INSTALLATigN TYPE CONSTRUCTION SPECIFICATIONS bd <br /> 00NITORING a HOLLOW'STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:___ <br /> 1!EXTRACTION p AIR HAMMtERIORIVEN CASING THICKNESS TYPE OF CASING: O STEEL p PVC 0 OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 11 AUGERS a HOSE <br /> 11 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> fl OTHER: a OTHER__ APPROX.BORING DEPTH g BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 418 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ol ces, Rules and Regulations,and all applicable California State Laws. <br /> Signed z / Title/Company 'l S FG l"'13c��.e isi <br /> Print Name Date `//f0 400 <br /> DEPARTMENT USE ONLY _ <br /> -77 <br /> SITE MAP IN UNIT IV FILE,ADDRESS-2j, 2.) O 111�4 'J` P <br /> WORK PLAN DATED: p / <br /> Application Accepted By J Date Issued L40 Area. <br /> Grout Inspection By Date---iv -Final Inspection By Date <br /> Destruction Inspection By Date---Tiv— <br /> x rQ'/ --- <br /> 1 <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC#. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 7 SERVICE REQUEST# INVOICE <br /> 31 �0v (00f bo, 1 -wr ?I / s <br /> C-57_ WC=WAIVER_- C-57 Letter of Authorization to sign permit_,Encroachment doc_-, <br /> BHD 29-02-00I <br /> W22m4 <br />