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AO' <br /> DATE ISSUED L ) AREA 5-v? 2 <br />FINAL INSPECTION BY /CA/La-la DATE, I fit 05 <br />DATE <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.orgiehd <br /> <br />SITE <br />MITIGATION <br />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 Department. <br />s40.4.10 zip it z 3 /1::ceesislitor's <br />SF/SC P-f-er.k- Zip ‘95Z 0.3 Phone # (0 ')9) 91"/C °2-L/6 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />gNEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') D DESTRUCTION (CHOOSE TYPE BELOW) <br />0-SOIL BORING# ic (airrox) 0 OVER-BORE DIAMETER <br />LI WELL # 0 PRESSURE GROUT CI *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />A ID loS Lic# 05-V° Phone (3()2- 817g <br />Consultant/Sub Cntr E g- 5 Address U 00 Riuiero 4-3 I ° city 06-1h1Ac7L eiw-t-LiceFITt2 )phone s) 13f- (6'3 z) <br />Well Location 01 1,3 Cross Street <br />Property , <br />Owner r <br />C-57 Contractor C..fro ssecioLkesAddress <br />I\JAv City <br />12_01 u,_), (AjekSio:+14 ri City <br />-3,c/ -r- r tieCity <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />CI MONITORING 01 HOLLOW STEM DIA. OF BOREHOLE 2- 1'0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br />0 AIR SPARGE/OZONE '<PUSH POINT (GP OR CPT)._ GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />yt,SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH 1-4) 6 0 <br />0 BOLTED TRAFFIC BOX OR LI STOVE PIPE <br />COMMENTS: <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicable California Laws. <br />Signed 7 Title/Company OA' d e-1 C4 <br />Print Name Dat.0 ) 7/0 <br />DEPARTMENT USE ONLY 2 <br />- ( :(ri , 0/, 01 eid, Y ; <br />(;:tH <br />SITE MAP IN UNIT IV FILE, ADDRESS: 041- 6 <br />WORK PLAN DATED: <br />COMMENTS/CONDITIONS:--A- • /)S <br />S6 _s -L/3" <br />r1-) Y4Y1Ldexi.4 <br /> <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br />4oi r <br />7 <br />, <br />..._ 4:/ - //a N- (C1 /67(b/C23 S R# 0,1 (-)Ft(X <br />F AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 11/5/07 (WEB) WELL PERMIT APP