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.;an Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd I V <br />Well Permit AprjUpgM9R5 pM G: 50 V <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAXf TE ISS <br />Application is hereby made to San Joaquin County for a permit to construct and/$r it 1!#&� E"rb This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San 4i1jrlrPxl? jgealth Department. <br />Assessor <br />WELL Location yyt{ mo55n13t,E a Cross Street �Nrbl2irl4T�-S City L'4-TH-teyP Zip HS 0 Parcel# 3y -D30-03 <br />PROPERTY <br />OWnerRCE SOVODtS P'6:TPLEUM Address `P.O,&, -73tL/_ CityS K -7 -o,' -J Zip9,sZG-?-Phone#;20V-95,2-Dkb$ <br />C-57 Contractor (aY2e66 W2410 -JC, Address iso OoWe Ax/E7 Cityl°1MLT /y Zip`s ISY3 Lic# Ek'iD Phone#9a25-3i3-.5-800 <br />Consultant/ Sub Cntr.,4d✓- ddress 82.7 Shaw /U City S121t"- Lic#7 680127 Phone# <br />GIS Coordinates: X <br />Y <br />Township <br />Section <br />WORK TO BE PERFORMED: <br />$NEW WELL / BORING (�PT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />',SOIL BORING # GP ''t and G P -r 5 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE � 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALS FfC- --rf) TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE *'USH 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 6 Yee- 2- :ar> !a n d <br />p OTHER: 0 OTHER APPROX. BORING DEPTH 156' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinan , /�' <br />1 and egulations, and all applicable California State Laws. <br />Signed x �' Title/Company V'fCe Preside^^ <br />Print Name K_D�ev`i' /V 4'j+ Date J O n v A r o S 2-007 <br />DEPARTMENT USE ONLY q t "01 <br />SITE MAP IN UNIT IV FILE, ADDRESS: 44-4 M o 5 n d a) e -Road <br />d <br />WORK PLAN DATED: JAI o-fe-m h e r 22� 2 00 L aril D ce_e 5-w hem 13 2006, <br />Application Accepted ByL. Date Issued 11/Sa[)Gr'm t Z," 2-007 Area! 451_ <br />Grout Inspection By '-"A ..r -Date 2. _ Final Inspection By4,' ,+6rid i12e r�rlls, Date f 50 D <br />Destruction Inspection By n Date T 1 <br />COMMENTS / CONDITIONS: Ad Va n c e rt-, P 5-L: ti <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT SERVIC EST # <br />INVOICE <br />3501 <br />zi35 op <br />3 . 00 <br />SR# 004q3$3 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ nc -h hent-doc <br />EHD 29-02-001 <br />6/22/04 <br />