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San Joaquin County <br /> 2 7 2008 Environmental Health Department SITE <br /> m 600 East Main Street, Stockton,,CA 95202-3029 MITIGATION <br /> IF <br /> ENT qU* H68-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> o IT/SERVICE <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a peril 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 l V� —MLCross Street Of 0 AV City 1 0C'\�0 C� <br /> Zip 15 J-)'(/Parcel#rs(5; Z <br /> - 6H-t 1 <br /> PROP ERTYMc L4Rf�`W Address ' Wr v""dV1 ty1 City « Zip 952 PhoneJG^ <br /> Owner `` l (n� y n \ �I�,I 11� <br /> C-57 Contractor J�IIP�A/r G11 IJ/1\1l rill CAddress 1` v 1Q1'_ fcA Cily 'D � Zip 1 I ic# Phone# r�7 - 09 <br /> Consultant/Sub Cntr�� ` I�SS�(.1 N4 �_Address I i�l Wt0' Mn�Lic# Phone* 10 � 122' <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> J�NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) p DESTRUCTION (choose type below) <br /> g SOIL BORIN.Q# p OVER-BORE. DIAMETER <br /> WELL# 3 g PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> E MONITORING *OLLOW STEM DIA.OF BOREHOLE g MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> E EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS(h 40'11'u(.TYPE OF CASING: 0 STEEL [(PVC g OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL � / TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> g AIR SPARGE1 OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yesyq No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> E SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N➢NL- C Q n P'G-I <br /> g OTHER:_a OTHER APPROX.BORING DEPTH 5Ca BOLTED TRAFFIC BOX or B 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ortrances, Rules and Regulations, and all applicable California State Laws(. <br /> Signed x � <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: tjej}5' rdjagL. S-4— <br /> WORK <br /> --WORK PLAN DATED: <br /> Application Accepted By Dale Issued S/Z T 112 Area <br /> Grout Inspection ByAS IAd c� Date 5- 2S ,.�,. <br /> O Final Inspection By ftsre.— _Dale .5-/ <br /> � <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3701vq.00 11 t f a� eg SR# 5'13 Sv <br /> zggloo /zb� <br /> C-57_ WC=WAIVER_, C-57 Letter of Authorization to sign permit-!/ Encroachment doc_ <br /> ERD 29-02-001 WEB <br /> 9/11/2007 <br />