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Aan Joaquin County AEMU- <br /> Environmental*F0 <br /> Health Department SITE <br /> 600 East Main Street, Stockton,CA 95202-3029 FEB 14 20MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> ENVIRONMENT HEALONIT IV <br /> Well Permit Application PERMIT/SEnytIBES <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 /> � Assessors <br /> WELL Location pt3�' V--M;tow Cross StreetCQ.�`�TtAi Cily5hjc ='a)" zipSGAID . Parcel# ONC 080 <br /> ow°e E��1n PYt �d �od� ^Imo?) I.�i r i c cily5a��w g1)'Jtz q(S� arm - *fl►Z- toZSD <br /> C-57 Contractor?YtGtal OI-Z.51%114N11 re att)%% F_SSte`4 City o l[�ZipQ l Lic#�_Phone#51D-A -46 <br /> c C:� 30o rda r- <br /> Consultant/SubCntrF-N5k WIr� Address -*Z:2-0 CirAaWANd Lic# Phone#JS10-�ID'ct.�1,K1 <br /> ee��tt���� f t w t I <br /> GIS Coordinates:X&65s 6. 's ,YJ.\�'I?'ct ti'.ct9 ,Township 1 1.1 g Range l7 E Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING P GEOPROBE,HYDROPUNCH,HAND-AUGER, THE ) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# "" I�• o- t—15 DOVER-BORE. DIAMETER <br /> WELL# P-1 F'-2. 3 IMA-L}' IM1� - W-5' a PRESSURE GROUT <br /> *Other rM i-RS- wix:p C( msp-w GROUT SPECIFICATIONS <br /> COMMENTS: t rOtt m.»-lz. MIR 115 VAr-p t4 M=P v5 Mxp-V O Mrp `- c1b.1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �MONITORING p HOLLOW STEM DIA.OF BOREHOLE�� a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:__ A_ <br /> u EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL O PVC a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a s a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS C'E1M'2tC?I' UgJp�Jf d{b 1-t-4— <br /> THEIR: *THER IV'Pr APPROX.BORING DEPTH "+WUQUI, a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: tAMOUNETREMITTED <br /> FAC# <br /> PE CODES FEE INFO CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />