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NGV,-e7-2007 1 i:23 �At'1BR IA /� <br /> O, 1707 935 6649 P.04/05 <br /> Sa® Joaquin County <br /> Environmental Health Depa�^n.nellal/ ftJ�" SX ITE <br /> 600 East Main Street, Stockton,CA 959"P. ZU0 MITIGATIONITE <br /> (209)468-3449 Fax:(209)468-3433 Web;www.&&;& , [ f <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPI <br /> RES 7 YEAR FROM DATE ISUED <br /> S <br /> Application Is hereby made to San Joaquin County fcr a Wrnrt to construct and/or Install ft wmk described. This application Ig made In carnDlian�wprR San <br /> Joaquin County Developmerx Title,Chapter 8.1115,3 and the Standards Of San Joaquin County Environmental H®eNh Department. <br /> WELL Locators sl�.lYJA\�C � µ�MrCa76ST• <br /> '3 1.-tea _Crotae Street �.�, . Assessors <br /> PROPER caw Ib �ro �jgLziO SZO� Parcel H <br /> Owner Addreos Y L S N, r l�n�a.e�e City a 7J sl(jZ q-7'7 S ?L 6 <br /> Ael- P�PhonaQ 7�Oq a"�-,-ti►t <br /> C-67 Contra <br /> AddteAa Q�¢ i�C1L�.�____City " <br /> ti�j Zip iciQ Phonon_4?L 3 13 sr� <br /> ConsuftaMiSubCnv_ C-(t Yk- Addreas \S'gVG� �+t�rt��j C� �UI���S� 6�PRone v <br /> s <br /> GIs Coordinates,x y Townshb,r. <br /> ip Range _s_Section <br /> WORTS T4 eE P6RF4Rla�>� . <br /> -+NEW WELL/BORING (CPT,GEDPROBE.HYDROPUNCH,HAND-AUGER,OTHER•) Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# <br /> WELL >� I a 1 C- 0 OVER-BORE. DIAMETE►�_ <br /> *Other 0 PRESSURE GROUT <br /> COMMENTS: <br /> ND') iri S f�1icJ Z 1 Z Ob° GROUT SPECIFICATIONS <br /> TYPt- INSTALLATION TYPE CONSTRUCTION 8PQCIFICAT]ON9 <br /> MONITORING '&HOLLOW STEM 6^r DIA, OF BOREHOG a r' <br /> �aC19 D MULTIPLE CASINGS d1ntULTI-LEVEL_ WELL CASING MIA: Z <br /> D EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS SC),`4 0 TYPE OF CASING Q STEEL )PVC Q OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT S>AL 4on 't Q TREMIE TYPE TO BE USED: ffAUGERSz.- RHOSE <br /> U AIR SPARGE1 OZONE 0 PUSH POINT(GP ar CPT)GROtJT SEAL PUMPED.. 'SYes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING a HAND AUGER GROUT SPECIFICATIONS C <br /> Q OTHER: BOTHER - APPROX-BORING DEPTH SIJ 11 1-7 ?ZOLTED TRAFFIC BOX or Q STOVE P'PE <br /> COMMENTS; CONDUCTOR CASING PROPOSED Of YES,list speaiflcatlons In comment sectlon) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certf4y that I hays re rod this pfication and that the work will be done in accordance with 8nn Joaquin <br /> County Ordina e , and all applicable Cal romla State LAWs. /� y n��j <br /> Signed x lj�yuQZ_ D &—I h t7 ri r MA+i <br /> Ti1fe,Comparr/ �� <br /> Print Name �� Datc ` ( ' 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 11!FPLE,ADDi2L85; _ .2 O �/. Q_"Q r tele- 1A/ <br /> WORK PLAN DATED:/ N ov e�]-�T 2-006 <br /> V <br /> Application Accepted By, 1 C_L 0 r 1 O, C C.1]Y tY]t Q N Date issued - 1 4-' , Area 1 <br /> Grout Inspection By s oY i A L, !1Z f,&2 r}nam Date 2 A 7- -OS Final Inspedlon Byyi c/h r_-,Y)1 L ¢ato <br /> � z_13 _64 <br /> Destruction Inspection By Date <br /> COMMENTS 1 CON0IT1ON8• I rn p / <br /> t ACCOUNTING ONLY; AIDA ��', <br /> IIIIII FAC* <br /> I PE CODES PE6INFO "OUNTREturTTED I CHECK* RECD BY DATE PERMIT36RVICEREQUESTtt INVOICE <br /> 3501 89.Ga 84. 0 ZD©LG vw 11-14/-0�7 S 005- 257S_L_ <br /> C-57_ INC_-WAIVED_ C-57,Letter of Authorization to sign permit_Encroachment doc_ <br /> r13D 29-02-001 WEB <br /> 9/11/2007 <br />