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r <br /> �o utly �o San Joaquin County ORIGINAITE <br /> Environmental Health DePartment <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 952r,!,- (;v ,_, :1,� i;MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.oli �"-JL' J L UNIT IV <br /> �1FnR�`p Well Permit Application PP IAM art 0 q 2 007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS ,, TT �/ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe'I' 15( IQI��"IIT Mr compliance with San <br /> Joaquin County Developmentjitle,Chapter 9-1115.3 and the Standards of§an Joaquin Count'En ronmerif�]�iEahU3 t5epajfr e1-1 <br /> }T, •r-, p�/L L,--Coo ICS i Assessors <br /> WELL Location $r. K Flo Cross Street citySTo( Zip') 2- Parcel# <br /> PROPERTY u)1A10blJ1TY A" ;M- M. STe. ?,-7 <br /> owner $(ZDoKSIbE 6)0L'C_ Address (341 W,F10e)II""i"City 4;roCkTot l Zip U7 Phone# ( 6`4- 4`1 ZZ a <br /> C-57 Contractor PG -e*M_OR ktoN Address City Zip Lic#'g�a�Phone# <br /> Consultant/Sub Cntr Sf_"V_T wI lwyT1K4,10ddres0 fERrLAUri� �jQ�i CLQ jL ic# �:�2 Phone#�u�/ 341 <br /> IG.t-5L4­'i G ZD+-674- <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )rAEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) V/ESTRUCTION (choose type below) <br /> Q SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# f(PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS y ArT <br /> COMMENTS: TeMWy=A$`( -<,NAL�,OW C)V-0Ut-�b W A:`(SIS, C-)R,48 SAMP IF c.r-_j\AC-*'r <br /> W02K PLAN <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSDIA: N J <br /> a MONITORING 'HOLLOW STEM DIA.OF BOREHOLE b� 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING <br /> a EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL D PVC 0 OTHER: "i 6P�'P <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL )S MA-f- TREMIE TYPE TO BE USED: 'GAUGERS a HOSE <br /> AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: *tg'ges No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> V'SOIL BORING HAND AUGER GROUT SPECIFICATIONS 13�N�O Ai�T>: SLURRY O N ep�T (,EMEND <br /> a OTHER: 69-AD OTHER APPROX.BORING DEPTH L 1 S BOLTED TRAFFIC BOX or a STOVE PIPE <br /> c)W _ CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: NSA A`7 C' AS106, ` LiAC-V-F1Lt. (.W�T4 6f,00I AS Wi -n-- )tzpwO <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, les and Regulations, and all applicable California State Laws. <br /> Signed x � Title/Company i�RLS1 SEN 1 / S+r�T GDNS>>l.Tl N��, 1 <br /> Print Name _T Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNITIVFILE,ADE : <br /> E�: <br /> WORK PLAN DATED: <br /> Application Accepted By - Date Issued I' bl flY Area 6 V <br /> Grout Inspection By Date . Final Inspection By Date �- <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# / <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE P QUEST# INVOICE <br /> SR# V pA°l36°t <br /> C-57_ WC C-57 C-57 Letter of Authorization to sign permits Encroachmen oc__)� <br /> EHD 29-02-001 <br /> 6/22/04 <br />