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COWEDSan Joaquin County <br />2 7 2008 Environmental Health Department <br />600 East Main Street, Stockton,.CA 95202-3029 <br />ENT 6 T�68-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />" IT/SERVICE <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 1 �1 / N� � Cross Streety��� �y 1� City VnCy\J Zip j `h Parcel# 15 <br />PROP <br />Owner 1 ( � `` I+� ry Address _ QW �i \City 1 r�J11 Zip 15zt,1 Phone#ill �1 7 - 747 <br />C-57 Contractor �� n^,\ A In Address (('\�VtQ�' ��A City. �D Y Zipj�[Vic# Ph.ne#707 <br />Consultant/ Sub Cntr �SS� (_ 1 N�< Address 111� I.0 V1Q 6q)# Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />FAC# <br />WORK TO BE PERFORMED: <br />r <br />[ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH. HAND -AUGER. OTHER*) p DESTRUCTION (choose type below) <br />--�r- <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />`. <br />WELL # 0 PRESSURE GROUT <br />sr9-o0 <br />-0 2-11-1=b0 <br />0 Other GROUT SPECIFICATIONS <br />GtF <br />COMMENTS: <br />�+ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING [f}tiOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS '�i h 40 ibi TYPE OF CASING: 0 STEEL DPVC 0 OTHER: <br />D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />C <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 10 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N 2 in P <br />0 OTHER:_8 OTHER APPROX. BORING DEPTH3n 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 Or nances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 5 +A G o 0) 14 h � 55)t 1 k5 <br />Print Name Q h I ) Date 'L—g —oy <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 1 1 1:;- I n-. <br />Application Accepted By Date Issued S / L� I O Area <br />Grout Inspection By W > �c -+-` Date 5A -!A_ Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVIC <br />INVOICE <br />35-01 <br />so <br />sr9-o0 <br />-0 2-11-1=b0 <br />Y`66} <br />GtF <br />f z}� SR#0pS`{3 S0 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit EncroslQc <br />EHD 29-02-001 WEB <br />9/11/2007 <br />