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FILE COPY <br /> an Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT IV <br /> ` Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DI✓- 03--pesr WRtL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Locatkml(ott�D CCtfhljr'(&-1A Dr. Cross Street f•At.11S[ 'T�Ity 1-{troP zipq 3� Assessors 3 3 <br /> Parcel# lj`41 O 2 <br /> PROPERTY A ar <br /> Owner QrACv Kh!ndA tTR L.Address 2'}000 S. Lp.EWgrrJhity TrG�Zip K30 Phone# <br /> C-57 Contractor WDC gN?lorC4+ior) Address15et l�Ur1'h� Q,� n ary ¢unoh Pqs$ic# y6332!Phone# Stb-$}3 _.30�� <br /> Consultant/Sub Cntr .SECOlz Address 3ol-a ytu ore a/o> City_42 v0. Lic# Off Kt S Phone# ftt&— ( -.30:3 <br /> GIS Coordinates:X 37, 8 lv ,Y —121. 2,83 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) g DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ZWELL# 1 ("p-A N("p— gPRESSURE GROUT <br /> 11*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATTIONS <br /> E MONITORING ,4WOLLOW STEM DIA.OF BOREHOLE' '' g MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:3I�_ <br /> a EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS 0 TYPE OF CASING: g STEEL a PVC g OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEALEAL lk TREMIE TYPE TO BE USED: g AUGERS g HOSE <br /> RAIR SPARG OZONE g PUSH POINT(GP or CPT)GROUT SEAL PUMPED: E Yes '&No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING g HAND AUGER GROUT SPECIFICATIONSt 1PQt CQky-t6a - <br /> a OTHER:_U OTHER APPROX.BORING DEPTH 'Lo/ "BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED ...n1 /TDr`— <br /> (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or i ances, Rules and Regulations,and all applicable California State Laws. <br /> Signed r1 l/ - � Title/Company S"k 5_4erl+i St /�E CO(Z <br /> PrintName Aml3Ff- V- N(C.LG"S Date -$ 'OS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: &V IO <br /> WORK PLAN DATED: /2 -/2- D ° D <br /> Application Accepted By Date Issued y- t7 Area <br /> Grout Inspection By. Date IFinal 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 PERMIT/SERVICE REQUEST# INVOICE <br /> 350 �35z�8 Zrz SR# Q�3�OS <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_ Encroochment docN.Q <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />