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San Joaquin County <br /> Environmental Health DepartmeAE (CES'4EID' SITE <br /> 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.orM". 0 7 2008 UNIT IV <br /> F Well Permit Application ENVIRONMENT HEAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSBERMIT/SERVICES <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 /> '!� IAssessors 2 ) a 1 <br /> WELL Location I I15 � , Flnl\N�l\J`�Cross Street <br /> MR;y\ <br /> City (, � <br /> l) OZlp Parcel# I7J`g )/ <br /> OmerPROPAddress <br /> ( T 1 Address I I/A�G� r1NY\AII&A1City v Zip Phona# <br /> C-57 Contractor lJ"✓� TKS,�1,t Address 9I O Kd/I1��de lKil City V Zip Uc#6S6Y0�r�hone#915-313-5b00 <br /> Consultant/Sub Cntr�T Sl1tSiU�'l�5 Address \II7 W(\Q f& �6 P J Lic# Phone —4 5)`�-) Zti� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 6 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 1 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLF4:4_�Y\0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1-O TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 3WUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N zii - C 0 1n1 t n, <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH 1-LO 0 BOLTED TRAFFIC BOX or 0 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 Ordinances, Rules and Regulations, and all applicable California State La s. <br /> Signed <br /> Signed xUn ""M ` Title/Company <br /> Print Name �p� Tr nIiAIhXM at <br /> DEPARTMENT USE O Y (� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C 5 <br /> WORK PLAN DATED: 1 S b <br /> Application Accepted By Date Issued ; t 3 Area <br /> Insp on <br /> Grout Inspection By Final By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMOUNT RE D CH # REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3s 3 z9V <br /> V. <br /> / SYS G� � SoS SRI' S 233 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit Encroachment doc_ <br /> EHD29-o2-ooi WEB <br /> 9/11/2007 <br />