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,o o On Joaquin Cdunty` L} ��z,rU� � Y <br /> EnvironmentalHealth Departmenl>E�`�`°"� 'u� lr SITE <br /> t 600 E. Main Street, Stockton, CA 95202-3029 OCT 2 3 2007 MITIGATION <br /> o (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ENVIRON11,017 ( HEALTH <br /> Well Permit Application PERMIT/SERVICE <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 9-11155..3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location _(0q l2v(i,L,Loer�t (/r: Cross Street 1"fir h'2 City S'�Gkwn Zip ySZ�7 parcel#to 13 oa# <br /> PROPER7. L7 D_ �1�� / <br /> . <br /> Owner SS Lri /-!!11 Address loLy LL11nvrti(+add o+'. CitySiJ� -iC& Zip gsZa7 Phone# ZCV-`<75'- YoyK <br /> C-57 Contractor W,1dA(/�'�-1( Dnr��'n Address s� n``^'^� �� d-��X ;C t) 60 Ui11i Zip� �7/ Lic#?I'O?f Phone# 707-37q-V3,40 <br /> Consultant/Sub Cntr ,/ g AddressPVC1 "/ct'n/44e,.Nrl/, 14 CityLic#/7G 6 r6 Phone#4'16-3&z-710o <br /> GIS Coordinates:X 38,060 y --x1, -- ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> gNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) U DESTRUCTION (choose type below) <br /> a SOIL BORT ffFF a OVER-BORE. DIAMETER <br /> Ir <br /> WELL# W—I.S a PRESSURE GROUT <br /> p'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE A. 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2 L�= <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS o.IS ihTYPE OF CASING: U STEEL APVC a OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 2-4 TREMIE TYPE TO BE USED: GAUGERS p HOSE <br /> a AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes S No (NOTE: MAXIMUM FREE-FALL/DEPTH IS 30')� <br /> U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 3a �° 'k Se / 27-Zy y� N <br /> U OTHER:_0 OTHER APPROX.BORING DEPTH LIS H. XBOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /V'6 (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 /> I 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 Reg uI ti ns, and all applicable Californian State Laws. Y� <br /> Signed / Title/Company <br /> Print Name t�r�G S. S,�C � Dale 1U/ZZ /U7 <br /> DEPARTMENT USE ONLY RwB( L6r <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 560 `' 3) ��r3CoQ.9$r 2 .5l <br /> WORK PLAN PP P DATED: Date Issu n <br /> Application Accepted B ,+:`-ED Area 68 <br /> Y <br /> Grout Inspection By Date Final Inspection By Date O 54 d <br /> Destruction Inspection By D to <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2Ro Mv�/ gq to ar a SR# 0573$5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_(74jAta.x-t <br /> EHD 29-02-001web <br /> 622/04 O <br />