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08/10/2007 16: 32 2094683 EHD PAGE 03 <br /> _ Irr San Joaquin County <br /> SITE <br /> Environmental Health Department ITIGATION <br /> 600 E.MainStreet, Stockton, A 95202-3029 <br /> •� <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov_org/oh.,;r it v X007 UNIT IV <br /> Oa*P <br /> z,�• Well Permit Apple anon �_;;;-;;�;!::;?;i,ic(WT ✓,iEkl: <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y AR FROM DATE ISSUE`D'� i l„ii i J_it V1rFC <br /> pplication is hereby made to San Joaquin County for a peril to construct and/o nstall the Work described. This application r5rtlads in compliance with San <br /> mquin County Development Title,Chapter 9.1115.3 and the Standards of San J quin County Environmental Health Department Assessors <br /> Stree Ctty _TOCKxJYoZipParcelfk2-��f0-� <br /> YELL Location ?500 /)�Ail'i l iUL -Cross <br /> DROP ,V 11j City yp/. &Phone 9 �7rc.� <br /> Jwner_�t,��sr ��� Address 0 <br /> jdeil <br /> -57 Contradory �)f $t ,p p.� /A1� Address 0 Cily, L/t81 Zip9Llctt ,7—Phone <br /> CoNOo¢�aArLT fit Address /9S Psi!W 7' City1Toze-nwy Lic# ---- Phoneoj,� >r __d <br /> Consultant/Sub Cntr /7 <br /> , -� Range Section <br /> ' '> �"�' /��n/ lint Township <br /> GIS Coordinates:Xl] K/_ L,59 n!.-,Y <br /> WORK TO BE PERFORMED' <br /> g'NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND- GER,OTHER-) O pE ER .BORE.STRUCTION <br /> DIAMETERchoose type below <br /> O0 SOIL BORING# ^ _ 0 PRESSURE GROUT <br /> oWEL-k4 �)>`7/Jvl GROUT SPECIFICATIONS <br /> 0*Other _ <br /> _ COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONS TRUCTI N SP IF CATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE // 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING' 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 1]MUD ROTARY DEPTH OF.GROUT-SAL^'g�3 TREMIE TYPE TO BE USED:- 0 HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMP : 0 Yes 1*110 (NOTE: MAXIMUM FREEFALLDEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICAT NS <br /> OTHER:j �7p �0 OTHER APPROX.BORING D PTH ^� S —0 80LTE1 T FFIC BOX or STOVE PIPE <br /> T_C[!.l\ CONDUCTOR CA51 PROPOSED Aj(7 � (if list SPecif o;s i;comment Section) <br /> COMMENTS: / 5-ToeEJ1A'c l ' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCES AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE' REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepare this application and t t the work will be done in accordance with San Joaquin <br /> County Or ' �lnces, Rules and g lations, and all applic ble California State Laws. <br /> ille/Company A-- -- � ]7��sM�jJ.)L•C1l i ?— <br /> Signed x I <br /> Date_ g �--- <br /> Print Name / ! � <br /> DEPARTM T USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: `G 5'f"> Wt> r' <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued 41 Ol'� Y Area <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> _ :ACC7OUNTING ONLY: AID# I F <br /> FEEINFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# o�sl SR G <br /> C_57 /yyG_�sWAIVER_ C-57 Letter of Author ation to sign permit�Encrlwchment doc, <br /> 6/22/04 RECEIVED 22RECEIVED TIME AUG. 10, 4: 24PM <br />