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OCT -02-2007 16:52 rgMBRIA <br />�Q"JuL VU"%,jUAAA %,UUULJ' <br />Envirinmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />1707 935 6649 P.02iO3 <br />SITE <br />MITIGATION <br />UNIT IV <br />0����J�IYJIL. <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 DeJ opmegt Title. Cqa3 Y r�1 tgf g 1 5.3 apq the S}andards of San Joaquin County Environmental Health Department. <br />� <br />- _ PC- 4MArMs 'L:- .50.Te7/ E,%,O� Assessors <br />WELL Location Cross Street f City .` Zip Parcel# 241-/ 0-4 <br />PROPERTY <br />Owner G:T�a� fl., Address 5 q A.brK �:� Avg <br />City zip 9 done#_ _Z 9 f ---G V- 7,1 00' <br />C-57 Contractor%t.>t�•<,, 0nEGI!JAddress l "" Dr:mac City_. Ip j$71r1-Lic#V110WPhone# 7(4 �G3P-5o5Cy <br />Consultant I Sub Cntr . =* ,�} <br />4 •1QvWr3 �A _Address�yVq je, ce&Je0r,%c city 'Lic# Phone# 767-9357 3 7 <br />S«: Lc too <br />CIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED, <br />p NEW WELL / BORING <br />0 SOIL BORING#_ <br />0 WELL # <br />a "Other <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />r6 <br />4DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER -_ <br />$PRESSURE GROUT <br />GROUT SPECIFICATIONS_ P..CN,-J "'�•P 4c,.,r, <br />TYPE - WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS It <br />MONITORING 11 HOLLOW STEM DIA_ OF BOREHOLE" f 2 &MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br />p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSS k YQ TYPE OF CASING: U STEEL J'PVC BOTHER: <br />a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS ArHOSE <br />Q AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS or ki. Tzar.4 <br />n OTHER; I7 OTHER APPROX. BORING DEPTH_. p BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED /VAS (if YES, list specifications in comment section) <br />I, -..FG[ L- It b e Gl+4re.� ` ��+.Lv is G.:��ir r�Sr4rr "W"v vt-h�.r !w• �a�� . <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREE�NT OR L'�NCROACHMENT PERMIT: <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 Ordinances, Rules and Regulations, and all applicable California State Laws, <br />Signed x��Title/Company� 4? <br />��-0r /i <br />- e✓r%� P W-3-504� <br />Print Name�a� [..+ 4 _ _ Date /C <br />SITE MAP IN UN <br />WORK PLAN DA <br />DEPARTMENT USE ONLY <br />Application Accepted By,�,(► L"/�fA���G/� i _-� Date Issued y40 -S- 0 �% Area _/ s9 <br />Grout Inspection By Date V Final Inspection By Date <br />Destruction Inspection By V f J-41 i I,& tkod-� %%lies. Date 110- / 1 -^"7 <br />COMMENTS I COND <br />ACCOUNTING ONLY. I AID# I FAC# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # RECD BY I DATE IT / SERVICE <br />3502 16 0.00 1 (0. 0 0 40045 i0-5-0'7SR# 0 0 5 2 195 <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ <br />EHD29-oz-ooI WEB <br />