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ORIGINAL <br />San Joaquin County 119UUM32 <br />Environmental Health Department�, SITE <br />600 East Main Street, Stockton, CA 95202-3029 N(, d 2 7 2007 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjg0v.P 6NMENT NEALTy UNIT IV <br />Well Permit Application PERMIT/SERVICE <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 />/ Assessors <br />WELL Location ISO 2- N• Q all. Std Cross Street City Zip IS'20Y Parcel# /2 7— 0?0 - le <br />PROPFO—' 9c�2s <br />Owner- "il4ddress ���i3�1_�J �Oy City Zip J_ 'hone# ��d' �ji7 5'16 <br />C-57 Contracto <br />Consultant / SL <br />GIS Coordinates: X31.'?/—l_, Y-1Ll - 2f3 , Township <br />Range, <br />ie# :ZZ • 9V6 *1960 <br />010 r'(/- oylJD <br />Section <br />WORK TO BE PERFORMED: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />ANEW WELL / BORING <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 DESTRUCTION (choose type below) <br />DATE PERMIT EQUEST # <br />[] SOIL BORING # <br />0 OVER -BORE. DIAMETER <br />[] WELL # /y11✓ -1•g <br />1roU . W-2Zf SP—/ <br />0 PRESSURE GROUT <br />LPO <br />[] *Other <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />A4A Ploy !� Y -re rd .` afine,,f <br />a«d <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING [] HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSa qO TYPE OF CASING: 0 STEEL )(PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S 3s TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS -1 lclHtr-.1 <br />[] OTHER: OTHER So N c APPROX. BORING DEPTH 7 -r -Y- BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED * (if YES, list specifications in comment section) <br />COMMENTS:(1) 2" 11,16 1 71"ksa 2"4kll /. yf .ejr. /n' 0 020_rcMre � /2 ';0�3 It,4 z',Er iLAred <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 Ordina e/s�Rules and Regulations, and all applicable California State Laws. <br />Signed x // �/ Title/Company 1 �COlof"a�c'� X,./ <br />Print Na —Date A <br />SITE MAP IN UNIT IV FILE, AD <br />WORK PLAN DATED: <br />Application Accepted By, <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITION <br />DEPARTMENT USE ON Y <br />/V, <br />�U&Moj <br />Date <br />_Date Issue <br />inal Inspection <br />D6d�; <br />!�—OQ <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT EQUEST # <br />INVOICE <br />R#V <br />C-57 ✓ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit r/ En_cro Z`p , oc <br />EtID 29-02-001 WEB <br />9/11/2007 <br />V <br />y <br />