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• . I • iLE COPY <br /> doo <br /> San Joaquin County� , Environmental Health Department SITE <br /> h K� 600 East Main Street, Stockton, CA 95202-3029 NOV p 9 8007 MITIGATION <br /> m (209)468-3449 Fax: (209)468-3433 Web: Aww.sjgov.0 /ehd UNIT IV <br /> ENVIRONMENT HEALTH <br /> Ty <br /> <4t Q ' Well Permit Application PERMIT/SERVICEIS <br /> NONREFUNDABLE 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 575( P .L ✓E�ILL� Cross Street ) •N.city,j!_{JJtl�q[__Zip 52-07 Parcel; <br /> PROP +C ?+ Address IOZ7 W / <br /> Owneryr <br /> ob Mhat�L-Dl• Citync�'fWl Zip J1107Phone# q <br /> C-57Conlractor VifOflfJ�: Address5292 Pa CJ31v<I CilyY ECJ Zip9y55.3.ic#7 27Phone#/15-J121'�y9( <br /> Int <br /> Addressylq yG Lic# Phone#91 7� ..`O w <br /> Consultant/Sub Cntl2rn�.1/LL• Cit <br /> GIS Coordinates:X .A. 00230N ,Y 12,1 .5178OW Township_. Range Section <br /> NAD83 <br /> WORK TO BE PERFORMED: <br /> EW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') B DESTRUCTION (choose type below) <br /> SOIL BORING# �✓ n OVER-BORE. DIAMETER <br /> n WELL# PRESSURE GROUT <br /> B'Other GROUT SPECIFICATIONS <br /> COMMENTS: ✓'�� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING B HOLLOW STEM DIA.OF BOREHOLE B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA:N_ <br /> U EXTRACTION -10IR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: B STEEL B PVC B OTHER: <br /> VKAPOR a MUD ROTARY DEPTH OF GROUT SEAL N TREMIE TYPE TO BE USED: B AUGERS n HOSE <br /> B AIR SPARGE/OZONEXPUSH POINT(GP or CPT)GROUT SEAL PUMPED: BYes^ B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> B SOIL BORING B HAND AUGER GROUT SPECIFICATIONS Nn <br /> B OTHER._B OTHER APPROX.BORING DEPTH 5 B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> V� CONDUCTOR CASING PROPOSED fl (if YES,list specifications in comment section) <br /> COMMENTS: ('ObfJ I1 �aC" <br /> -prob� locaicon t, ;ll bEbad:TS/1fid lJiltV rovf aF £nh aF woc )Gdo <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AG EEMENT OR ENCROACHMONT 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 Ordi ances, Rules and Regulations,and all applicable California State Laws. <br /> Signed / Lr,.,. Title/Company <br /> Print N <br /> Date tI D <br /> DEPARTMENT USE ONLYOlt <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 'J 7 cta r t e <br /> WORK PLAN DATE6.'. -� <br /> Application Accepted By Date Issued Area 06 <br /> Grout Inspection By le Final Inspection By to 12 -/0 07 <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Z20 el, � '?M?n - Ct�tc u-I-a7 sR# Qrj 2 <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 />