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San Joaquin County�t �tmwm <br /> 'op. . .y.•co <br /> Environmental Health Department SITE <br /> a 600 East Main Street, Stockton, CA 95202-3029 MAY 0 7 2008 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: "'j' <br /> " <br /> ' v�1N.UNMENT HEALTH UNIT IV <br /> QLIFO¢�tP Well Permit Application t PERMITISERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES i 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 Title,Chapter 9-1115.3 and the Standards of San J aquin County Environmental Health Department. <br /> �^� ,J I,� I- Assessors <br /> WELL Location llf0 + 1�O�l��l r�tn��rCross Street 11�1 V city 5+v-1L'loh 1Zip ll PL/arcel# NYA <br /> PROPER �� ��� I V Il �t74 Zi L�I Phone# <br /> Owner �h \j Bayr �� Address h cc�� City P (J <br /> C-57 Contractor& _ Address 5 1) trl t,0 ���y�.ChY '� iP Lic#64015T,'hone#_I ��,13- j)(i <br /> Consultant/Sub Cntr Q Address )II�1 i.�, Ya,N11 ?1 City �Lic# Phone#�0 A"ZZ21 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 00 OVER OVER-BORE. DIAMETER___T (choose type below) <br /> n SOIL BORING# <br /> 0 WELL# p PRESSURE GROUT <br /> p"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE - 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL 0 PVC n OTHER: <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL_VLL�L TREMIE TYPE TO BE USED: GAUGERS n HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP Or CPT)GROUT SEAL PUMPED: lkYes 0 No r(,NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS I°P�� lY`, I 0 U� <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH I'l C� n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 Or innc�es, ules annd Regulations, and all applicable California LState Laws. /I}Tr (< <br /> Signed z „�`{[LAN'J^�I`� Title/Company ' I0, j C e 0 15 71 I ` hfJ tliq <br /> Print Name Pet Q Y I�Y1lio LW r\ Date 21 -d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: rAa% 5 <br /> WORK PLAN DATED:_4k <br /> Application Accepted By Date Issued 3/0 sj Area <br /> - <br /> Application �/ <br /> Grout Inspection By 1.17^^ e•.-. Date S c `! Final Inspection By (�� r-E� Dale f I q �o <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# 4BY <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# DATE PERMIT I SERVICE REQUEST# INVOICE <br /> $9.00 / Ys s�,a o8 SR# 5q 2-32 <br /> 35x3 `r °' <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit / Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />