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I hereby certify that I have pr <br />Coun dlnances, Rule <br />Signed x <br />Print Nam <br />Jun.,27: 2007 2:21PM o. 1607 P 2 <br />Jan Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgiehd <br />Well Permit Application <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 Josquin County Environmental Health Department. <br />sessors <br />WELL Location ‘' le '1T( t4 ,- c 6--( X./4- Cross Street City 51-e. c.- -'-k-,-.^*. Zip I c Le' T) Parted* <br />, As <br />Ownee \-- -1.- Sr '' t ("1-1::..- k- ddress 1-1-0 \ k.) • \i,,,L )1,,,,,,,,„,c_.,,i.„ --,.Zip 4 c2-crsphone# to .‘ et 1 e- -0 z .- <br />PROPMY <br />C-57 Contractor Contractor fle..._ T Address °Z. Z., la , f-i.4 5 4; Citt.Jcie.i L. iZip1S-4 11.L1c# k 0 Z 3311phone <br />LOK(.4.11- <br />451.-_7_42:----) <br />Consultant/Sub CntrC laS 7---AC (:.° Address ) ?----, i‘..‘ Q-cm- )4" -- City L re-,z. Lic# (( I.C.-- /4 67 Phonedi <br />1, 1c0 <br />GIS Coordinates: X <br /> <br />, Township Range <br /> <br />Section <br /> <br />WORK TO BE PERFORMED: <br />[i NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') Li DESTRUCTION (choose type below) <br />SOIL BORING fl OVER-BORE DIAMETER <br /> <br />(EtWELL U PRESSURE GROUT <br /> <br />LI *Other GROUT SPECIFICATIONS <br />COMMENTS; <br />TYPE OF WELL <br />O MONITORING <br />[I EXTRACTION <br />0 VAPOR <br />INSTALLATION TYPE <br />[1 HOLLOW STEN, <br />a AIR HAMMER/DRIVEN <br />U MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE2-14 I MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS I .-.)t TYPE OF CASING: 0 STEEL a PVC II OTHER! <br />DEPTH OF GROUT SEAL -7") TREMIE TYPE TO BE USED: 1:1 AUGERS HOSE <br />a AIR SPARGE/ OZONE *USN POINT (GP or CPT)GROUT SEAL PUMPED! [I Yes U No (NOTE: MA)c17),IM FREE-FALL DEP IS 30') <br />?(SOIL BORING a HAND AU 1-1" GER GROUT SPECIFICATIONS 41, t <br />0 OTHER: a OTHER APPROX. BORING DEPTH 0 — a BOLTED TRAFFIC BOX or [I STOVE PIPE <br />COMMENTS: \ kt)c- 9-1k <br />CONDUCTOR ASING PROPSSED (If YES, list specifications in comment section) <br />5 d'rv---c 1 77k--1 --,c_ <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />ared this application and that the work will be done in accordance with San Joaquin <br />Regulations, and all applicable California State Laws. <br />Title/Company ia-v <br />Date <br />C 1F—S <br />t / O1 <br />Z2.6 1 kits <br />WORK PLAN DATED: ri q tjj 2-0 0 -7 <br />Application Accepted <br /> Date 76 I 0 <br />Biy- <br />Grout Inspection By -1 Final Inspection By <br />Date Issued <br />Date Area <br /> (7-, (7, # <br />Destruction Inspection By Date <br />COMMENTS / CONDMONS <br />ACCOUNTING ONLY: <br />.1..imom <br />AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITrED CHECK I/ REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />NI (-3)(-7 --. _ r- it, i___ SR# cr 5 i 1 .? 3 <br />-FLA. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:6 <br />C-57 we <br />END 29-02-001 <br />6/22/04 <br />-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc