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0 ���T <br />San Joaquin County RECEOv�D <br />Environmental Health Department OCT 2 2008 SITE <br />600 East Main Street, Stockton, CA 95202-3029 OAQUIN coUNTMITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orftVIRONMENTAL 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 />!V` Assessors <br />WELL Location 3LLt2 1' ( �- Cross Street i s t City f tkl t zip _Parcet# <br />PROPERTY1 n <br />�* ts Zip ""k7" 'Phone# l <br />s_ i[J" mid <br />�tCt,rtlx: <br />1 �t'G Sin ll� E? t wL f "�� � s ,U <br />C-57 Contractor \, Address CityjZip Uc# Phone# CPQ <br />t ,)12.`-I I!`'AAI A S -t'- e t -7f 3 <br />Consultant/ Sub Cntr m, k ti'•t TA 04G � n� Address S L e . ?C City �X'\ Lic# 3�a Phone# t - K t <br />I a ,',j t' yn �3 <br />GIS Coordinates: X -�2 U4 "(2 L I) 5 , Y ��y i Township i Range U Section <br />WORK TO BE PERFORMED: <br />> EW WELL / BORING <br />p SOIL BORING # _ <br />P WELL # <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />Il DESTRUCTION (choose type below) <br />a OVER -BORE_ DIAMETER <br />8 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />/ai //— .9 z_4 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />it AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: p STEEL a PVC OTHER: " <br />p VAPOR <br />p MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />D AIR SPARGE! OZONE <br />a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes <br />p No {NOTE: DEPTH IS 301) <br />U SOIL BORING <br />p HAND AUGER <br />GROUT SPECIFICATIONS <br />iMAXIMUM �FREE-FALL <br />�'� V Y1�&'L i lLt <br />r <br />�bTHER:1 OTHER <br />APPROX. BORING DEPTH <br />p BOLTED TRAFFIC BOX or 'STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <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 OrdinanWs� Ryles and Regulations, and all applicable California State Laws. <br />Signed x fr /,�R�(�r Title/Company /dSSGev% 4e <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: _ <br />Application Accepted By v a <br />Grout Inspection By e <br />Date Issued �� 2 ® Area <br />D O Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: <br />11 ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC`D BY <br />DATE PERMIT/ SERVICE REQUEST# <br />INVOICE <br />3 Z <br />!o p SR <br />C-57_,.,. WC _ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EVID 29-02-001 WEB <br />9/11/2007 <br />