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,oP4"•'�•�o San Joaquin County E C'0 P Y <br /> y % En`..onmental Health DepartmgL /F�C � I) <br /> SITE <br /> 600 East Main Street, StocktCn, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orgA1?S — 9 200$ <br /> P UNIT IV <br /> A/�FORN` <br /> Well Permit Application ENV!R0NMILEjT HEA . <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �,9'T��� �/I��J <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 Location M PD W126W /Q",q-j7 Cross Street W,CV City fKl��( Zip �arcel# rs �/' <br /> (J G-r� p <br /> ERC' <br /> Owner IT-,E L L:0 5 TP)3fY LL address Z6n C-?C-MW4WA V1? City lU�l�/�N�E Zip Phone# 3/0' 1--/ 6 <br /> �� <br /> Sl Dr:IL1.IMC �Z�7- <br /> C-57 Contractor 7 Address 27- N.EAS(5>rzEB i City W00a-ANO Zip ls-�74Lic# 02331 Phone# 5.30 40-24 Z t <br /> Consultant/Sub Cntr 191#16 Addreps Q iR&1 h144- Cit QFM# Phone# 1�29' <br /> GIS Coordinates:X Y '1�1 . a 0 Township p2 -� Range O y Section 13 <br /> WORK TO BE PERFORMED: <br /> 'NEW W LL/ BORING (('PT.tOPROBY ROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> SOIL BORING#_ (yrs-�Z []OVER-BORE. DIAMETER <br /> 0 WELL# ' <br /> []`Other_ PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: 2 6,6OP2(/�� �'lle,iUE,s / <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE3,2-S []MULTIPLE CASINGS (1 MULTI-LEVEL WELL CASING DIA: <br /> o EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS IVA4 TYPE OF CASING: 0 STEEL 0 PVC a OTHERA -t : <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 717— <br /> `L S TREMIE TYPE TO BE USED: n AUGERS ROSE <br /> a AIR SPARGE/OZONE 1p�USH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes <br /> >0o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORT 0 HAND AUGER GROUT SPECIFICATIONS /v 1✓f.T- <br /> /Ty"THER:W rl� OTHER APPROX.BORING DEPTH 3 []BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED w (if YES,list specifications in comment section) <br /> COMMENTS: Y�1L`6E VJAJ61,SWI1-L 14 k/EcL 14&11 C, &&6T LFj=50Cr—A 02C—PACiLEv:�2 <br /> FIL-JE4� (- 1V deo wG CA51N6. <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 prep red this application and that the work will be done in accordance with San Joaquin <br /> County O ' ances, les an rulalons, and all applicable California,State taws. <br /> Signed Title/Company <br /> Print Name > St VA, Date -7 <br /> DEPARTMENT USE ONLY Z9 O <br /> SITE MAP IN UNIT IV FILE, ADDRESS: fU' `1.. �c, 01Q <br /> WORK PLAN DATED: W-0 / i <br /> Application Accepted By Date Issued d Area loy/ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> [[ACCOUNTING ONLY: AID# o% FAC# <br /> E CODES FEE INFO AMOUNT REMITTED PHECK <br /> # REC'D BY DAT ' PERMIT/SERVICE REQUEST# INVOICE <br /> S R# o� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Si94 p rmit Encro ment doc_ <br /> EHD 29-02-001 WEB ' <br /> 9/11/2007 v/j <br />