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° <br />San Joaquin County <br />L Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9520fE8 0 1 2007 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov UNIT IV <br />ONMEW NEAI D' <br />1 �t�i RN`P Well Permit Application PERMIT/SERVICES <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 Emkonmental Health DepwIment. <br />I � (i f - <br />AMESSOrs <br />WELL Locetb { t tAf-t L.rN tL D Cross Street J 5vF-r--6T' City _LHTtt P ICIF' Trp `1 S 3 3 L Parcel#_ <br />PROPERTY -� {L ( ��'- Cfc C•` La44\rc C (T 0 .t3U}( qVj i t?a I yl_tj Cr KL f 145 % - - <br />Owner V <br />C -V <br />Consultant / Sub Cntr f?N V <br />jg-.2O <br />_r c� <br />GIS Coordinates: X Y!_ Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL I BORING (CPT, GEOPROBE, HYaROPUNCH, HAND -AUGER, OTI4ER•) (I DESTRUCTION (choose type below) <br />Q SOIL BORING # Q OVER -BORE. DIAMETER <br />� <br />WELL * rn w 15 Fel mw 15-6 Q PRESSURE GROUT <br />Q .Oth- GROUT SPECIFICATIONS <br />COMMENTS: -1 +- <br />HYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS - -�Ic E- NE LL d <br />Q MONITORING <br />I HOLLOW STEM <br />DIA. OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 2 <br />1 EXTRACTION <br />Q AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 11 STEEL il PVC Q OTHER: <br />Q VAPOR <br />Q MUD ROTARY <br />DEPTH OF GROUT SEAL \/`XI­� t s TREMIE TYPE TO BE USED: 0 AUGERS Q HOSE <br />Q AIR SPARGE/ OZONE <br />• <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOT EL MUM FREE -FALL DEPTH 13 30') <br />Q SOIL BORING <br />Q HAND AUGER <br />GROUT SPECIFICATIONS„_ Cj' iY\2��,"� <br />Q OTHER: <br />D OTHER <br />APPROX. BORING DEPTH -2-5-',A0 �C r 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED (I YES, list specifications in cormnent 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinarprmj.tules and Regulations, and all applicable California State laws. F-Nvst N IviF-NTA L - <br />Signed x <br />Print Name 11qxr e <br />Title/Company ` -Kjof- Ff1C�Ih1�Ef'-- �%'f MG"Aifc nl c wt i� <br />e I c `1 <br />DEPARTMENT USE ONLY I <br />SITE MAP IN UNIT IV FILE, ADDRESS: I <S(� D C - +ice AU zg �A te-0 <br />WORK PLAN DATED: ' C �J <br />Application Accepted By <br />Gate Issued a Area <br />Grout Inspection By Date Final Inspection By Da3��3,� <br />Destruction Inspection By U Date <br />COMMENTS f CONE <br />ACCOUNTING ONLY: j AIDS <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT FwwrrED <br />CHECK S RECD BY DATE PERMWW / # <br />INVOICE <br />.� ✓ , <br />I 31 <br />col SR# <br />C-57— WC.---�- WAIVER— C-57 Letter of Authorization to sign permit_____ Encroachment doc_ <br />EM 29-02-001 <br />6rMA <br />