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PA'�'�vED <br />San Joaquin County FiECE <br />Environmental Health Department OCT 2 2008 SITE <br />600 East Main Street, Stockton, CA 95202-3029 AQUIN couNTYMITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov. E IRONMENTAL <br />UNIT IV <br />Well Permit Application HEALTH DEPARTMENT <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 Department. <br />t Assessors <br />a - <br />WELL Location 3ZLt2 ' '4� (jzU'o S�.- . Cross Street t vi' City � Om zip Parcel# 1 �'T_ b 0ZA <br />PROPERTYr K1't°Address t t `.. City Ziptea+ 2�'Phone# ..) <br />OwnerC-57 Contractor .2`l ' 111�_Address City Zip U h5 Phone# CtaS_ =7419 <br />Consultant / Sub Cntr Vin kf iJr v i ')Address u r 4. ?. City 3c a e;-'\ Lic#}' a5 c� , Phone# ' <br />GIS Coordinates: X'�ZG Z_p Y5 V; Township l � Range l,i"�,` Section <br />WORK TO BE PERFORMED: <br />N-fjEW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />[) SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL # 0 PRESSURE GROUT <br />Other -i, ' }} til nn Y e it \kv Sc v'u1. GROUT SPEr"GiCAT'nNS <br />COMMENTS: 1 of, Il Dye, �x 1'64actt A' % O 95 <br />TYPE <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS jl <br />0 MONITORING )fiOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC OTHER: ' <br />n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO 13E USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM ��FRREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS y)b-f �:.�.yii ai P �ti. <br />kOTHER: Vel* 0 OTHER APPROX. BORING DEPTH3�i 0 BOLTED TRAFFIC BOX or STOVE PIPE <br />i j, CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS:' A t� t W 81-` Ike, v&li t Ue. tks <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 Ordinan s R les and Regulations, and all applicable California State Laws. <br />Signed x ;j.>'1 Title/Company �SSSG, k khf �� c ie l 'fgt fps 21. <br />Print Name G .,.N'V– (itZ Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /� y <br />Application Accepted B �G3+r u -�' 7 �4 ri Date Issued l® 2 0� Area <br />Grout Inspection By M e Date : �dA Final Inspection By C !!i �t !J <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT! SERVICE REQUEST # <br />INVOICE <br />L <br />Pg— <br />E31 <br />o og sus �_ <br />C-57_,. WC 1 -WAIVER_ C-57 letter of Authorization to sign permit_ Encroachmen't' doc— <br />EHD 29-02-001 WEB <br />9/11/2007 <br />