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P/ l /re Yr�,� azh'�yN7 <br /> 0an Joaquin County <br /> Environmental Health DepaSITE <br /> " 600 East Main Street, Stockton, CA 95202-3 2 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.orjM0 13 2008 UNIT IV <br /> Well Permit Application <br /> ENVIRONti1ENT HENL <br /> NON-REFU"nABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSPIRMIT/SERVICES <br /> Application is hereby made to San Joaquin Cou, -,trust and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title, <br /> g1Chaapterr 9-1 �u o - rnaquin County Enwronme al Health Department. <br /> essors <br /> WELL Location <br /> T��i� U�/.'/ ;.4 r� ` —City <br /> �ziPq�z,� P real# t <br /> PROPER �J 600 P&VlC//w ILAY �lyty� k� rA+r+C/O /(,/ - > 1. rt K/ <br /> Owner - n A r� "�lir,pct - Zip ( Phone# <br /> C-57 contractor1 pT oV�. �.�ol r� CilyzipyLidFhene#.2099zi.P-/3N.5� <br /> Consultant I Sub Cntr CityLic# Phone# <br /> GIS Coordinates:X ,Y Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> n WELL# ll PRESSURE GROUT p/ <br /> _^Other 1 ,4 6&J- GROUT SPECIFICATIONS—AL '/ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS <br /> 0 MONITORING _HOLLOW STEM DIA.OF BOREHOLE //' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA-, 7 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL jjkVC 0 OTHER: <br /> 0 VAPOR V 1UD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,es B N (N E: MAXI UM FREE-FA/f DEPTH IS 30') <br /> 0 SOIL BO N`G�� 0 HAND AUGER GROUT SPECIFICATIONS /VPLL. ivn1/✓!� <br /> �THER: re, OTHER APPROX.BORING DEPTH 11n_u'(j/ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �r� CONDUCTOR CASING PROP SED (d YES,list sp rations in comment se on) <br /> 7��s1 ! r <br /> COMMENTSr- t � I✓is �iCL, 1-1') '��O I Cr _ Ca v� ' Gi?r .n1r ,fC�-a' ✓_r,�JL. -�- F?�� %"'9 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U 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 Re lationsl and all applicable California State Laws. .- <br /> Signed x ~ Title/Company, <br /> r T <br /> Print Name Dat �.1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5 EC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> tail '2it.'o SR# DO�'z✓".3 <br /> C-57_ WC)/ -WAIVER_ C-57 Letter of Authorization to sign permitZ Encroachment doc� <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />