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a" an Joaquin County nn 2� P y <br /> ' aZ Environmental Health Department� CI�IIU (�L' <br /> 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ARP — 7 2008 UNIT IV <br /> g P Well Permit Application ENVIR01`,AlENi NE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR.FROM DATE ISSUEQRMIT/SERI/ICES <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 /> D6 �� sT Q,����yA d pn Assessors 43 <br /> WELL Location � Cross Street ��''r 'r"-eit ���ME _Zi _I 2-Parcel# J3/ ` r'-/�2gJ <br /> PROPER p�f I ,, / /1 r ��•".2lOfoT <br /> Ovmer r GLV''OS Sfv7b Y121y� Address%�7y,�� �1"II Uon _.,City L Zip`I 2017 Phone# /, /, Q ��Q <br /> C•57 Contracto S (t k� &7 ,?- �M�GC ��!Ig57-I t=ic#7175"' hone# YID 0B I�rCIY <br /> _ ,rte r. Addrea nnCpaity ll ,,,,II � <br /> Consultant/Sub Cntr � Address a 37 S kOA-21 R A CityStDCP 6 Lic# Phone# l� l /00(0 <br /> GIS Coordinates:X ' ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> dNEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) G DESTRUCTION (choose type below) <br /> G SOIL BORING# G OVER-BORE. DIAMETER <br /> G WELL# G PRESSURE GROUT <br /> G*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPEINSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,* <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE G MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: <br /> G EXTRACTION G AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: G STEEL �VC G OTHER: <br /> G VAPOR G MUD ROTARY DEPTH OF GROUT SEAL LD flafq EMIE TYPE TO BE USED: GAUGERS G HOSE <br /> G AIR SPARGE/OZONE G PUSH POINT(GP or CPT)GROUT SEAL PUMPED:Xyes G 1Noo (NOT MAXIMUM FREE-FALL DEPTH IS 31 <br /> G SOIL BORING G HAND AUGER GROUT SPECIFICATIONS Prrr-1 i¢I Z,,/ <br /> G OTHER: I2.a i,y BG OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: MW Ins-kilJ gad <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, <br /> Ordinancces, Rules and Regulations, <br /> egulations, and all applicable California <br /> L�State Laws. <br /> aws. <br /> Signedx tAj&y^ +' tie <br /> V - a- Title/Company <br /> Print Name WtIawl dke-, <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP INUNIT IVFILE, ^DDRESS: 30B Nor IL Grc, r1+ <br /> WORK PLAN DATED: Fe b r Lu a r 8 t 2 U o 8 <br /> Application Accepted By L. ey Date Issued 4 - 8 -08 Area 14 S 9 <br /> Grout Inspection Byt'� L,1i'IS/Arhte�Date -f-t7_-Ot Final Inspection By jIP}lY id L,rhddlir, ate 5 -3-08 <br /> Destruction Inspection Byf Date <br /> �r' L <br /> COMMENTS I CONDITIONS: 1YCS4- 11,C+;D, orie, ,e <br /> EACCOUNTlNG ONLY: AID# FAC# <br /> FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 294 nd 383. 00 27306 `f '1-9 -oE SRO UOS383 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> FHD 29-02-001web <br /> 6/22/04 <br />