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San Joaquin County <br /> <br /> <br /> <br />Enyirt nental Health Department _ SITE <br /> <br />600 East Main Street, Stockton, CA 95202-3029 !FE= (-) irk,//' 'MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd - —UNIT IV <br /> <br />Well Permit Application OCI 2 5 2007 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" /RONMEN i HEALin <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This.apPllication is made in compliance with San <br />Joaquin County Developm nt Title, Chapter 9-1115.3 and the Standards of San Joaquin Cot Environmental Health Department. <br />I f 40 L m Assessors c• <br />WELL Location Mao r A•teAl-eCross Streetd504.4-Wit.";-^ City Zip /5.33 -/ Parcel* Z 6i- 0 20 - Mar <br />C4 Owner C._ Address 31F Vi5 City A.SelvA.6Zer/-So-g,..Phone# <br />, q :3 C-57 Contractor 6eca., Address 1,5-0 ,e4,7_,) City /-1../4"te"Zip Lic# 5b • °I-none# <br />amikr-.5 Consultant / Sub Cntr6,..e47,3 tocri. (-Ass° Address !n it? %&,..),J41 Clr•-ez City 3‘,"0".•.. Lic# c." 23cn <br />GIS Coordinates: X , Y Township <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />XSOIL BORING # 2. <br />WELL # ORIGINAL 0 *Other <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_2 1] MULTIPLE CASINGS <br />CASING THICKNESS PA TYPE OF CASING: 0 STEEL 1:1 PVC ;6-aft <br />DEPTH OF GROUT SEALe4i,•Jerk. TREMIE TYPE TO BE USED: At HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: ['Yesp,.No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS P.( 1,--1 -4/4-7 <br />0 OTHER: CI OTHER APPROX. BORING DEPTH 4 CIO% 0 BOLTED TRAFFIC BOX or l] STOVE PIPE <br />CONDUCTOR CASING PROPOSED /kJ° (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 tIis application and that the work will be done in accordance with San Joaquin <br />County OrdinanceRule and R'gulà4ons, and all applicable California State Laws. <br /> Title/Company <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: / 0 W. Yo.Sini; 71-e-- A ti.nv-e._ <br />WORK PLAN DATED: Max 24 2,607 <br />Application Accepted By Vi.e.i--Dr;a L. A/1 e_ r <br />Date Issued r)e.,±1) e-e- 3) 2.40 7 Area 45-q <br />Grout Inspection By Date /1 1‘ / Final Inspection By <br />Destruction Inspection By Date <br />A dVa, d vi i_ PT -2. on g/r- COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />. .. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PE -1. : Ei:Ist.ç <br />35-0 I <br />01 <br />99.00 cif 81. c--& 0 0 4-4 (-(z)-i-7 /0- SR# <br />s. oosz4-65" - , <br />PROPERTY <br />11S-313 -Skoo <br />Phone# 70-7-1.23- 24.ar <br />Range Section <br />El DESTRUCTION (choose type below) <br />['OVER-BORE. DIAMETER <br />1:1 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />['MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />a MULTI-LEVEL WELL CASING DIA: iY,01_ <br />Signed x <br />Print Name 0, A -7'N/Ai--1)1-'1'1\70 //, /Pi 5-/fic <br />rvb <br />C-57 Letter of Authorization to sign permit -Encroachment doc C-57 WC -WAIVER <br />EHD 29-02-001 WEB <br />9/11/2007