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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT C-. e: (209) 468-3449 Fax: (209) 468-3433 Web: www.siqov.orq/ehd <br />600 East Main Street, Stockton, CA 95202-3029 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />FEB 13 2009 WELL PERMIT APPLICATION <br />ENVIRONMENT HE ki-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />PERM T S RVIC Application Is her ma e o n Joaqu n 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 />Assessor's i <br />Well Locatio;;P•..sr 444 (-4)—r‘Cross Street ‘...) AP-16 City cli`g>41—#11--- 41% to% Parcel # to 3-0 ?02---" <br />ProperX <br /> Address 22.0 ‘.."1 City Ca—Pm- Zlp q•C.2101 Phone # 41) de er44.0 C <br />C-57 Contractor 'Pre.. Address -5C S- City 54 LL.- Uc#136337Phone "i r <br />Consultant/Sub Cntr.541 ` Address City Uc # Phone <br />GIS Coordinates: X , Y , Township Range Section <br />11.NpRK TO BE PERFORMED: <br />NEW WELLJBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') DESTRUCTION (CHOOSE TYPE BELOW <br />0 SOIL BORING* /F1 OVER-BORE DIAMETER <br />rIWEU_ # " c. *PRESSURE GROUT <br />9 *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />KMONITORING KHOLLOW STEM DIA. OF BOREHOLE 9 4 El MULTIPLE CASINGS 9 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS C.44 .+0 TYPE OF CASING: 0 STEEL ,'PVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL C - TREMIE TYPE TO BE USED 0 AUGERS HOSE <br />0 AIR SPARGE/OZONE 0 PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: 13 Yes Aii No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS .k- re...-: . e y-e---t 4. ! --• -e. "("1"1---, ck -tere-rs <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (If YES, IIM spedecetIons 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 p 'thIs application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />ReguL.es,jjid all appli a Cal omia Laws. <br />Title/Company T' C-rj <br /> Date <br />DEPARTMENT USE ONLY <br />9f-. SITE MAP IN UNIT IV FILE, ADDRESS: ?dal (A-142-3 P °. <br />APPUCATION ACCEPTED BY DATE ISSUED mg/ 7/01 AREA IV_ <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: A f PR. 0 cfP117 49 <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK • RECV'D BY DATE PERMIT/SERVICE # INVOICE <br />cpol 84 - 1?q - I'Mi4 ;hi PI sR# OD (i„cgz.. <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> <br />ENCROACHMENTOC <br /> <br />WORK PLAN DATED: beZ/ 'LOOS? <br />DATE <br />END 29-01 11/5/07 (WEB) WELL PERMIT APP