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TYPE OF WELL <br />JKONITORING <br />a EXTRACTION <br />a VAPOR <br />INSTALLATION TYPE <br />piOLLOW STEM <br />U AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />Date <br />DateDate <br />San Joaquin County <br />Environmental Health Department FED ( SITE <br />600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd _ <br />AUG 0 S 2007 UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUFE V_iRONMEN f fiLALi h <br />T\illf /UPVIr. made to San Joaquin County for a permit to construct and/or install the work described. T-Is app it'ation! is IT1 in compliance with San lopmr Title, Chapter 9-1115.3 and the Standards of San aquin County E vironmental Health Department. <br />, )Assessors <br />clj Zipq 5-21 Parcel# <br />Zip9 441Flhone#a33 20Z" <br />C-57 Contract° art/ C- Olddress 332-- ec r City r4.1C?4 s-Nzi,477 5ighon4)(4, Glen 69 <br />Consultant! Sub Cntr Abe-7 <br />GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />o NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />O SOIL BORING # <br />0 WELL # <br />a *Other <br />COMMENTS: <br />4 ESTRUCTN (choose type below) IO <br />OVER-BORE. DIAMETER <br />„z1DRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />CONSTRUCTION SPIFICATIONS <br />1 t /IC 6.1 DIA. OF BOREHOLE S'h,Cill MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:""" <br />CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC a OTHER: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />a AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: DI lo (NOT: MAXIMUM FREE-FALL DEPTH IS 30') <br />[I 0 SOIL BORING HAND AUGER GROUT SPECIFICATIO S t OP•11 10'IA <br />fl OTHER: OTHER: rl OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />i/ 13 Ak. C 1-7 Jt\S I A)? .e/t on co - s , 4 , s- , 6 1 "3 + <br />j. kONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: P( - <br /> <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 Lays. - <br />2 ) ' Signed x y A <br />V <br />Print Name <br />to <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 5c/tncc. ( S 4 L <br />WORK PLAN DATED: Fc by.t.kok 01 7_ 2-7 zoc)-3- <br />Application Accepted By (A\- <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAc# 6 - s.R.00,5-1 (0s <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # _.. REC'D BY DATE PERM ' - : • - • INVOICE <br />3 5-1:9.. 5 CA, • c, e SR# <br />Application is hereby <br />Joaquin County Dey <br />WELL Locatioa I. Of- (e0C1 1 Cross Street5e City <br />e r <br />owner r½ 14/e(1 Addresii--1?_/ Iv. Pi/4e'3fr4PIv PROPER''' • <br />Addres? smLAI RA Citt?xL2fl# Phone# 467 101Y, <br /> , Township Range Section <br />DEPTH OF GROUT SEAL L719 <br /> Title/Company <br /> Date <br />Final Inspection By 2_ C., <br />Date Issued S.. /13- I -7-- Area 6 2-I, <br />C-57 <br />WC -WAIVER <br />C-57 Letter of Authorization to sign permit --V'Encroachment <br />EHD 29-02-001web <br />6/22/04