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� o <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 952 �(`������ IGATION <br /> • (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.or / I �� l1,V lL, NIT IV <br /> 0 Well Permit Application 'AM 0 9 2007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS , ffT u�nt <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe pd tldn f94� 4 Mi compliance with San <br /> Joaquin County DevelopmentTitle,Chapter 9-1115.3 and the Standards of an Joaquin County En ironmerif fl { -S <br /> ` - O _ (00 I4S Cc� Assessors <br /> WELL Location r � t< + Cross Street CityS'1"OC�lO1J Zip°I�2_11 l# <br /> PROPERTY CO Iv1MUTJITY !1`h0C- t*, ,5Tf_ 1B=7 <br /> Owner FKSIbE 0L.F Address 1.141 Wr K013T+4iiWI)City S-[0( '1-Tots) Zip5sU7 Phone#Z-9) 64- 492-0- <br /> C-57 Contractor PC--e-IkOR k'TkO14 Address City Zip Lic#� hone# <br /> Consultant/Sub Cntr S�T2TCD?,iSULTIfJCa�10 ddressiyoo TERi�A l'-AI 'TI1 SL Iii c4Z`i32 Phone# q 16 '341-9Z0iS <br /> K.t�q T,Jr.14 %4. ZDf-6760 <br /> GIS Coordinates:X Y Township Range Section <br /> WO K TO BE PERFORMED: - / <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) VDESTRUCTION (choose type below) <br /> Il SOIL BORING# Q VER-BORE. DIAMETER <br /> Q WELL# IrPRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS g �(��1 E SW RR's oa< <br /> COMMENTS: `TeM?0V-Af- ( -<,1A A M to GT2oU0"b WA71✓R G*A E� <br /> Y2K PLAN DA�Ter,> 1- -0-7 A,-r-VA(+VV2> <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE b MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:N <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: -T6#A1' <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEA —MA-�-- TREMIE TYPE TO BE USED: LV'AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: V`�es 8 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `[SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 5f tJT0 Q IT>: SLURRY o fZ tI eK C.eM E! E <br /> a OTHER: GRAPE [1 OTHER APPROX.BORING DEPTH 4-15 a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> ,!5)t'j CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: HSA A5 (eM?62A" C,Asik)G - aAC-4--Fitt, WITi.A- eNfO'o AS WIT47>RAWO <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 Ordinances, les and Regulations,and all applicable California State Laws. <br /> Signed L�-tL.t�C I= Title/Company KESI1ETJI / ST �iU1`)SI�l.Tl1�1Cj, lA1C - <br /> Print Name 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:• <br /> WORK PLAN DATED:1 1121 7 <br /> Application Accepted By Date Issued L 1 61 L DY Area 6 L <br /> —T <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> SR# V o0t°t36°l <br /> C-57_ WCC-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_!�, <br /> EHD 29-02-001 <br /> 6/22/04 <br />