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IT <br /> G <br /> V!. ,o San Joaquin County <br /> 2 , Environmental Health Department SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 " 0 7 2007 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.ET0/ 0J1gf0ENT HEALTH UNIT IV <br /> Well Permit Application PERMIT/SERVICt. <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 <br /> Title,Chapter 9-1115.3 and the Standards of San <br /> n Joaquin County Environmental Health Department. <br /> WELL Location /0 / d �t7����0T' ]S. Cross Street/V C) N I C Ci ,/ L Assessors <br /> ty61Kn(/// Zip Parcel# f7� <br /> PROPERTY <br /> Owner 4gBA)EW PkoPJFR1te5 Address LO f2jCX IV02-ZO City 1&)C-0 SaC- Zip Phone - 6��0$l� <br /> ,J LLC <br /> C-57 Contractor /�SZ- Address 770 N, C.497'—S'T CityAd6W-::V-ip Lic# OL;3 Phone# Seo Z <br /> Consultant/Sub Cntr/517nG- Address 1117Z 0 A/C 01 M City Mo'DCf?bLic# Phone#5792-Zz I <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> .0-1415W WELfL-I BORING (CP HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 8-SOIL BORING# /— ,p, EOPROBE u OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> i <br /> COMMENTS: SC-F' X-7C' W rt'CAd 7 HLO Soto /.c C011 Ca'FIoL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR PUSH <br /> U OTARY DEPTH OF GROUT SEAL N L} TREMIE TYPE TO BE USED: <br /> Q AIR PARGE/OZONE POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTHDsecti�on) <br /> a-SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH a 6�� a BOLTED TRAFFIC BOX or a STOVE <br /> n CONDUCTOR CASING PROPOSED (if YES,list specifications in commenCOMMENTS: NEAT C�Ma%% - C, (LOLL `� H PDLL�I� l.J�Tlf T 6' YnmlE <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4eWOR G HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have preapplication and that the work will be done in accordance with San Joaquin <br /> County Ordin Rq'es-anons,and all applicable California State Laws. <br /> Signe Title/Company Ill fESS�d.�i�C C7�OL d /J <br /> Print Name' L� �>��c� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 10 9`j c6' <br /> WORK PLAN DATED: <br /> Application Accepted By t— Date Issued D �- Area Z/ <br /> Grout Inspection By LAN-c� Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: L- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z 0 L/ SR# 500-, <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit✓ Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />