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San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 952OfEB 0 1 2007 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov HEA <br />ONMEUNIT IV <br />NT �� <br />Well Permit Application PERMIT/SERVICES <br />NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br />Appkation is hereby made to San Joaquin County for a pem* to construct and/or instal the work described_ This appkation Is made in oomplance with San <br />Joaquin County DevelopmatY Tile, Chapter 91118.3 and •te Standards of San Joaquin County Environmental HOVM Deparbrowt <br />l c f� �L Assessors <br />WELL LacatIon I`� CC' S{ . t1AE��rti i-'r� Cross Street J Si�ET City L/VMI-'-;-'P 2p "i5 33C Parcel# <br />PROPERTY L -c -i C -� L�; �'!� f ) 1. --6,, :'1 Z <br />PROM- ^1i .� �. �n - 1 -RIi2!:0P . Z1n17ti-3UPivu 2-oq'?r�g���4s$— <br />tLLtN& <br />Ma4-1CA <br />t3 <br />C-67Conhactor Mr-..: rwnrneJU i <br />vywy-ajiZ PhAB "-32`1 SOg85- ^ 3g 1 <br />Cmmuna,rrt/SubCMr E;vV F-rMePiA lc-NM1 e f'Address ZZ7`) Lich Phone <br />GIS Coordinates: X Y Township Range Section <br />WORK TO W PERFQRMED: <br />NEW WELL I BORING (CPT, GEoPRoeE, HYDRoPuNcH. HAND -AUGER, OTHER") U DESTRUCTION (@wore type below) <br />lj SOIL BOR f �a Q OVER -BORE. DIAMETER <br />WELL * 3 r it\ �� f v 1 �ti i i 1 l by 9 y �J GROUT 0 PRESSURE <br />GROUT SPECIFICATIONS <br />011rar <br />COMMENTS:_ <br />TYPE OF WELL INSTALlJ1TTON TYPE CONST'RI ICTIQN SPgW!gATIQNS - S c E t'Vf L_L <br />Q MONITORING S HOLLOW STEM DIA OF BOREHOLE _ a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2 <br />EXTRACTION jl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: B STEEL I PVC BOTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREWE TYPE TO BE USED: Il AUGERS d HOSE <br />p AIR SPARGE! OZONE p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM1 <br />FREETFALL DEPTH is 30') <br />U SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS o c rri r -+ e' l -Z,-- l �'- <br />o OTHER: N OTHER APPROX. BORING DEPTH --2t r , � (_�4] BOLTED TRAFFIC- BOX or Q STOVE PPE <br />CONDUCTOR CASING PROPOSED (l YES. lst specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQWRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and the the work wIp be done in accordance with San Joaquin <br />county Ordlnanpes,�uws and Regulations, and all applicable California Staft Laws. Nvsf-� N Iv[F-rJrrk <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: <br />Appik%tion Acoapted By <br />Grout Inspection By "� <br />D9sNuc gm Irw4*ciion By <br />COMMENTS I CONDITIONS: <br />i%hilaf� Et`llall`(�k�- r/RJ-MF_piAT1L fQ G0[ZUi <br />MIR I /la l07 <br />DEPARTMENT USE ONLY <br />Dale <br />y I Final Inspection By <br />Iab/0? ._- iqy <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT BITTED <br />tHECK # RECD BY DATE PERMIT <br />INVOICE <br />SM41'$23 <br />C-57— WC --WAIVER_„_ C-57 letter of Authorization to sign permit Encroachment doc <br />» 29-02-001 <br />W22M <br />