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08/10/2007 16:32 20946834: EHD �./ PAGE 02 <br /> o a San Joaquin q unty <br /> Environmental Healtl Departme _., SITE <br /> H r nt �I��t1AITIGATION <br /> 600 E. Main Street, Stockton CA 95202-3029 !(";!`= - <br /> f !•I <br /> (209)468-3449 Fax: (209)46jAppeatioln <br /> : www-sjgov.org/ehd `-' :` UNIT IV <br /> `'K� "` Well Permi .ntion 7 <br /> NON-REFUNDABLE PERMIT FXFROM DAT�'IuF'S'V.pplication is hereby made to San Joaquin County for a permit to constll the work destinf ed•, Thid�appijga"jioA;is made in compliance with San <br /> oaquin County Development Title, Chapter 9-1115.3 and the Standardn County Environmental Health Department- <br /> Assessors <br /> YELL Location 25Dd Rtly )L� Cross Streeity p�Zip 9Sw.�. Parwi#/z7-1ge-!7 <br /> uROPEWg7y I. <br /> ')wnerfl- zy F9f 1�'rn�Y7AwJ Address I City - m:1. Zip Phonefi a ��/-r477 <br /> -57 Contractoryly fl0t7 7. K. /i1lAl. Address Q• City ZL1D1 Zi ZLic# Phone#-9 '30-XW <br /> CnvO'�r-q H /991Fes'kr K ES•i <br /> 'onsultant/LLSuub Cntr:21zUMb��yIF< 1A Y Address City - i'a , Phone#�-Z <br /> ;IS CoordindleS:� 7°5 '/6a d r� ,Y - /Z/61Dr/6r✓ Township Range l G. Section17 <br /> YORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-A GER,OTHER*) 1XbESTRUCTION (choose type below) <br /> Q SOIL BORING# ! a OVER-BORE. DIAMETER <br /> q xwELLaL p,���.x�rrac (PR253NFLGROUT Tg�vtuE- E4,n1�1EO <br /> 0 Other GROUT SPECIFICATIONS 540 <br /> OMMENTS: G - 1 /aFvreAy/E <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE FICA71ONS <br /> MONITORING Q HOLLOW STEM DIA. OF BOREHOLE I Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> !EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER' <br /> i VAPORU MUD ROTARY DEPTH OF GROUT S TREMIE TYPE TO BE USED: flAUGERS Q HOSE <br /> AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPEC Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIO S <br /> (OTHER: 462�,p OTHER APPROX.BORING DE H Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING ROPOSED (If YES,list specifications in comment section) <br /> JMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE R EQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that he work will be done in accordance with San Joaquin <br /> ounty Ordinanc , Rules and uladons, and all applicab California State Laws. <br /> ianed r. ��� TtlI(Company� F GGbZ. ,O.DD12[- SAY <br /> 'nt Name D Date ! <br /> DEPARTMEN USE ONLY —� <br /> 'ITE MAP IN UNIT N FILE,ADDRESS: -T­5 <br /> _ORK PLAN DATED: I ^z7 Zv <br /> pplication Accepted By lc✓1.. I Date Issued BI Lot v7� Area `L <br /> out Inspection By Date Final Inspection By Date <br /> 1struction Inspection By Date <br /> OMMENTS/CONDITIONS: <br /> _,CCOUNTING ONLY. AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC- D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> °toZ (ori_ P cDJ ( o B�Lo�vy SR# I9'5rIL97- <br /> -57 ✓WCC/-WAIVER_ C-57 Letter of Authorizoti n to sign permit ncroochment doc_ <br /> D <br /> : 29-02-OOlweb <br /> _2/04 RECEIVED TIME AUG. 10. 4: 24PM <br />