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2007 2.21PM <br />Saar Joaquin County <br />° Environmental Health Department <br />ANNOW 304 East Weber Avenue, 3rd Floor, Stockton, CA 9520 <br />• (209) 468-3449 Fac: (209) 468-3433 Web: www.sjgov.org/ehd <br />o <br />Well Permit Application <br />No. 1 607 P. 2 <br />SITE <br />MITIGATION <br />UNIT IV <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 Son oaquin County Environmental Health Department Assessors <br />Cross Street � City c,'tom'^ Zip � Parcel# <br />WELL Location r <br />PROP <br />r � <br />°-sPhone#tAddress CitylJel L- lzlp�LI, °Z33�{ph�one�­L4 7 <br />242 <br />C•57 Contractor S Address %. Z <br />Consultant/ Sub Cntrk- KS a.�C Address!'° `°=Ci�� Lim �� Phone# <br />013 Coordinates <br />Y <br />Township <br />w0 K TO 13E PERFORMED: <br />Q NEW ELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />Range Section <br />U DESTRUCTION (choose type beloM <br />SOIL BORING # In Q PRESSURE <br />E. DIAMETER <br /># Q PRESSURE GROUT <br />VvELL <br />GROUT SPECIFICATION <br />Q *Other <br />S <br />COMMENTS. ` <br />Z <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Q MONITORING p HOLLOW STEM DIA. OF BOREHOLY,-114'MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br />EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS 2 'St TYPE OF CASING: 0 STEEL Q PVC Q OTHER <br />0 <br />Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL —c 4. TREMIE TYPE TO BE USED: Q AUGERS HOSE <br />p AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes u No (NOT �I�uM FR �-FFAALSL DEP IS 30') <br />SOIL BORING 6 HAND AUGER GROUT SPECIFICATIONS N i- <- --}t <br />Q <br />OTHER APPROX. BORING DEP <br />Q OTHER:TH I O '" S p BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOASING PROPSED (If YES, list apeQifications in comment section) <br />rnuucuTc• ` !� � DCS tom' �' � � V� � �1 5 � <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 p <br />County-Qfdlnances, Ruleoa <br />Signed <br />Print <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 �J1�I �'T S+ ' <br />DEPARTMENT USE ONLY <br />- Piz <br />z - ,t <br />2,201 was <br />SITE MAP IN UNIT IV FILE, ADDRESS:` / <br />WORK PLAN DATED' <br />•Date Issued%1 T Areae! <br />Application Accepted By � /' ,N\ %` Date <br />Grout Inspection By <br />,�"( Date ' Final Inspection By <br />Destruction inspection By Date <br />COMMENTS / CONDITIONS: <br />PACCOUNTING ONLY: AID# FAC# <br />FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT EQUEST # INVOICE <br />S R# " <br />F <br />6S-9 <br />C-57_ WCWAIVERC-57 Letter of Authorization to sign perm) Encroachment doc <br />^ •_ <br />E14D 29-02-001 <br />6/22/04 <br />F, <br />c <br />