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PA <br />QED <br />San Joaquin County RE <br />Environmental Health Department OCT 2 2008 SITE <br />600 East Main Street, Stockton, CA 95202-302&N JOAQUIN COUNTYMITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgLehVIRONMENTAL <br />Well Permit Application HEALTH DEPARTMENT UNIT IV <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 />tt <br />WELL Location 32it2 ' t (1,1{ kAO S1- Cross Street 1 L`J rt City �) Q m Zip 6N Assessors seesors b Lym <br />PROPERTY h <br />Owner 1-5 (" t�kl <br />C-57 Contractor `1 ewF, ' <br />bvi <br />,112.y V,'W A St- <br />s�N��S� <br />Zip Lic#� Phone# <br />Consultant I Sub Cntr IV 1t t Itf IJi OV2 6 SI , `{Address S La e 4. ?W City 3C. <br />GIS Coordinates: X 12 C0 -1 Vo.. V. Y 16' i� 0 hitt Township i <br />WORK TO BE PERFORMED: <br />"'-�EW WELL ! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />Q SOIL BORING # <br />WELL # <br />other 11-' ° i t`i-tlN�tt" `V1°s*V, S+ vpl� <br />COMMENTS: �L4 .1 f f l i ,3 iipi <br />-iILPszv->L(s f—f <br />Section <br />D DESTRUCTION (choose type below) <br />p OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />a &1/— p 7v <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS jr <br />D MONITORING )1�40LLOW STEM DIA. OF BOREHOLE Ij MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA: <br />n EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL a PVC OTHER: �f <br />o VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br />D AIR SPARGE! OZONE Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: iMAXIMUM �FREE-FALL DEPTH IS 30') <br />D SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />j�bTHER: Ve& n OTHER APPROX. BORING DEPTH3 $_ BOLTED TRAFFIC BOX or STOVE PIPE <br />i j• CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: A ` o 1-' j (D vii k, t ks <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinanrqps _RAles and Regulations, and all applicable California State taws. <br />Signed <br />Print Name Date iti j z f L <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By /CA-r-zeirF <br />Grout Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />P7 <br />yd 8 Date Issued �z 2lo$ Area <br />®g Final Inspection By ? ,?�� l©lam v <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMITI SERVICE REQUEST# <br />INVOICE <br />ifof <br />C-57� WC_IWAIVER C-57 letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />