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02/28/2008 THU 10: 03 PAX 209463 SJC BHO OD02/004 <br /> +�•. o` San Joaquin Count <br /> Environmental Health Department SITE <br /> 600 Ea3t Main Street,Stockton,CA 95202-3029 F(Cs 2 6 2008 MITIGATION <br /> / (209)468-3449 Fax:(209)468-3433 Web:www,sjgov�f�p /ehd UNIT IV <br /> !r,cr�ti)Eror NfALTN <br /> Well Permit Application PEFftT/SERVICES <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 DVoqnt Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> 5.r[% S-/$' /V•-v y Qom,Kil� // Assessors <br /> WELL Location l✓r/f -Y . t mf, 3ti`CCSlreetl/o,1.,e..Dn,/G City 'r. -4-zp Parcel# Ilzr"16o/ <br /> PROPEPTY q <br /> Owner forF4g .54AI., Address/OIJ,Q,wZ OY 9 CilyS✓a k- Zip 9.SkQ.Phor�"G�� <br /> C-57 Contractor> ri w,�,ar rj ' '(ter CiIY. '+��-r l y Milo*T d�'-PhaneA. I -3 t -w) <br /> Consultant Sub CnV Address .Z•k -3.+ Cily�LUc# Phone# HOZ-9, j-.73 f.J <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ONEWWELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (Choose type balm) MC✓_z7 <br /> OSOIL BORING# OVER-BORE. DIAMETER <br /> — <br /> 9 WELL# A$PPRESSURE GROUT <br /> a•OthxGROUTSPECIFICATIONS­ �.,../C....t•..� <br /> C0MMENTSLE2S /C_u nir '�1-. ��/ 4~e I..r//&"y q"r t�:E... <br /> .s. Ca. r Lrt�:�n Z.J l Sc .•Cy. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (( <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE fo rrr` a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA y_ <br /> D EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS 2_�y!:TYPE OF CASING g STEEL $PVC O OTHER; <br /> OVAPOR 0MUD ROTARY DEPTH OF GROUT SEAL —30 TREMIETYPE TO BE USED: DAUGERS (HOSE <br /> n AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes O No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 9SOIL BORING DHAND AUGER GROUT SPECIFICATIONS Fu -,-z <<i,_,/- <br /> O OTHER D OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR WIN/G PROPOSED(B YES,list specifications In comment section) <br /> COMMENTS: I,/s// 1- 114, /'P.s.0.ra nre.eArd "'i44C A'.,n ,xi4._ ._/ J41_ <br /> NOTE: OFFSITE BORINGS REQUIR ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 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 Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Signed x /�� -—, 1. 76y 701e/CompanY <br /> Print Name—=/ n77Cf-'rte fiilfY� Date <br /> V DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: SYS' <br /> WORK PLAN DATED: (,, fis t Q.t h'k d 1 -1 <br /> Application Accepted By �y Date issued�2-$16 Area rl� <br /> Grout Inspection By Date Final Inspection By Dale <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# or <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29.02-001 WEB <br /> 9/11/2007 <br />