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San Joaquin County <br />- Environmental Health Department ,�(� ��, � SITE <br />30.4 East Weber Avenue, 3rd Floor, Stockton, CA,;9����-, I�� J L� MITIGATION <br />„ (2�109) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />1 % Well Permit Application MAR 2 6 2007 <br />L1'4l'ii irjIgt"' _"u t1� �� N(v",ENT f EALi! <br />PFRr,� IJE W i6UNDABLE PERMIT EXPIRES 1 YEAR FROM DATE! <br />�� iT i -e^^IT/�FRvI0ES <br />0 AIR HAMMER/DRIVEN <br />Z, <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. 1 his ftlicalion is made in compliance with San <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />0 MUD ROTARY <br />Assessors <br />WELL Location - 151 5. Ir1R/A/ STreeT Cross Street iasem1TY1M.City a& [f ECA Zip 17533e. Parcel# Z11-100-15 <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />PROPERTY <br />0 PUSH POINT (GP or CPT)GROUT <br />Owner VALUE /I�etcioQq.47io/I/CdrR Address /6.598MPAde+J ✓rsTADr. City�Zip96666 Phone# (Cal) Z95 -79e 3 <br />0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />61005ervice , rNc. <br />C-57 ContractorfarLeRATrU Address 1535 rNdus-7RraL ", CityftLTas! Zipp6!/Z Lic# ywtjMPhone#&99260- <br />60 -Dr. <br />0 HAND AUGER <br />,0 r.C-l8K z 6B <br />onsulta Sub CntrR.M &SAecja7E5 Address/6Yelrnevoloj.VISTA Cityp,,&�rLLic#/?r3S7S Phone#(t04495-ealo, <br />R# So too <br />GIS Coordinates: X Y Township Tes Range ] E' <br />0 OTHER <br />—Section—5 <br />l-ATr rade 37. 79 7S N 1-0n�! -121.21(.91 w <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) )(DESTRUCTION (choose type below) <br />COMMENTS: <br />0 SOIL BORING # OVER -BORE. DIAMETER a'oAA IZr <br />0 WELL # <br />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 <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 Yes <br />0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />R# So too <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH <br />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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x f/ Title/Company rrtMr� i7gL G9�/Ga 1 lC S <br />Print Name A:LtA9 ,L) W mir—H644'0 A/ Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1S lVlg t i.. S ly�oi,vy�r�� <br />WORK PLAN DATED: <br />Application Accepted By o.— Date Issued 3 2 IF o ;i- Area <br />Grout Inspection By L \�w.unrc.�� Date Final Inspection By � �Date c <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERM UEST # <br />INVOICE <br />3s oz <br />35'o <br />600a <br />S3`{ <br />!.� <br />3�Zg�o7- <br />R# So too <br />ZgSoo <br />m <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit <br />EHD 29-02-001 <br />6/22/04 <br />