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San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />4(8)3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />AJN 1 0 ANON -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />Application is h'y; jft'afW,r`§i jJc}atirpunty for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County De�QtoWp�ertt,Ti�lj, �r 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 184E Cross Street Hirsian I&ar1 City hol--!nn Zip�_Parcel# 03 - 19 f 0.) <br />PROPERTY <br />Owner Ph, I k jck r Address 18s-7. Pwin4ektA 6fultwkd City 71Mk-Mn Zip W-?Ocl Phone# X09 'j <br />C-57 Contractor Rclunnr,n ddress A3.7 .4ha&) klnoel City 366 klDn Zip Phone# po y - 447.16oy <br />Consultant/ Sub Cntr{*IyanEwi bmt-nuirenmeaW in,. Address 3zz 9ha,u A&1C1 Cityjja� Lic# Lj01�� Phone# 909 �li.�-moi. <br />✓ Y-121 / Township Range Section <br />AMOUNT REMITTED <br />GIS Coordinates: X (. •`L <br />REC'D BY <br />WORK TO BE PERFORMED: <br />U� <br />-gNEW WELL / BORING (CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />,*Other 3V / -,3V7 GROUT SPECIFICATIONS <br />COMMENTS: &,164: Pian r+laPd eS Hrwr .2608 -- <br />- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLEI a5" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: iv <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -MIR TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .5' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE jPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes g�No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS�pc T/7 R,(A incl Cc1`Nc nk <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH •5' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NIR (if YES, list specifications in comment section) <br />COMMENTS: ReGrerit1 1110rk P1011 CYAlirl A- Hoo .7668 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />c <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />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 Vi e pceii(bk? I J Pcipi. neoel GrnEnu;rnnmPnl AW <br />Print Name Robe,4. c r Date' Dg 1nRr <br />DEPARTMENT USE ONLY <br />FILE, ADDRESS: <br />SITE MAP IN UNIT IV <br />WORK PLAN DATED: s• S'O8 <br />Application Accepted By Date Issued Area <br />Grout Inspection B 7 Date Final Inspection B ate 7�� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit C <br />EHD 29-02-001 WEB <br />9/11/2007 Qu 5 S t /� <br />k <br />