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SEP-24-2007 MON 02: 17 PM GEOMATRIX CONSULTANTS FAX NO, 559 264 7431 P, 02 <br /> 0 0 <br /> 000 San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street,Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www,sjgov.org/ehd UNIT IV <br /> Well Permit Application <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 9-1115.3 and the Standards of San Joaquin County Environmental Health DeparmenL 12-4 21 21 S <br /> • Assessors <br /> WELL Location 28^01 V, aAAew 2- roes Street 04gjdj& Cit �44VA' Zlp 9620 Parcel# <br /> PROPERTY .p ��,�. ^ '-_� (�1) Ia S,3�D 32 <br /> Omer '_-'-_Address 1313 Zr?.'�Prrrr.wancG city�>4:rC§.-n: sip 520 Phone#;951-355 1�DRD13 <br /> Zlp80 LJ 638Phone# <br /> C-67Contractor 'PA¢cia[eru address 1091City +- 11. 9y 1 <br /> Gonfialtant/suh coirieHjy�/Lfy- Address 1281 [(UJ.�vi a.C- citydMo Lfc# NJ�PnonelF 65A-26H-Z535 <br /> ct"1T I <br /> OIS Coordinates:X 'Y ownshlp1p Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT G OPfROBE, HYDROPUNCH,HAND-AUGER,oTHERn n DESTRUCTION (choose type beiev/I <br /> U SOIL BORING# .3 d0d, U OVER-BORE, DIAMETER <br /> Q WELL# n PRESSURE GROUT <br /> U,Other GROUT SPECIFICATIONS <br /> COMMENTS: P..9M____o yi/L &'iz'lll �0 . .e,,;0 ,. jJ&ae.,.W& <br /> TYPE OF WELL INSTALLATION TYPE ENSTRUON SPECIFICATinS <br /> n MONITORING n HOLLOW STEM DIA.OF eOREHOLE_j!—' u MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA <br /> 8 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS_41 JA OF CASING: 0 STEEL n PVC U OTHER: <br /> 8 VAPOR 8 MUD ROTARY DEPTH OF GROUT SEALS 4jA4jdg& TREMIE TYPE TO BE USED: U AUGERS HOSE <br /> U AIR SPARGE/OZONE 8 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH!p0 y <br /> SOIL BORING U HAND AUGER GROUT SPECIFICATIONS See�rf)7� <br /> U OTHER: U OTHERr z APPROX.BORING DEPTH U BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED--(if YES,list spedflrations in comment section) <br /> COMMENTS: 1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTION5. <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 Regulations, and all applicable California State Laws. / y <br /> �.��,�""� <br /> Signed x f - .�I : Tltie/Company�e>cu'ry <br /> Print Name nA'D -w'(W & Pate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 'Ce", w44LL-91"'L <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued Lr d-t- Area <br /> Grout Inspection By -&�Flnal Inspedien BY to Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODESO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 0 A.er.+— vs d1 SR#�S2o� <br /> C-57_ WC -WAIVER_. C-57 Letter of Authorization to sign perml Encroochment riot` <br /> EHD 29-02-001 WEB <br /> 9/1112007 <br />