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u elan Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 FEB 2 6 2008 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:wwvv.sjgov.oehd UNIT IV <br /> EWIRONh1ENT HEALTH <br /> Well Permit Application PERMIT/SERVICE <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 D v lop1r�ent Title,Chapter 9-1115.3 and the/Standards of San Joaquin County Environmental Health Department. <br /> 5.WELL Location Le/l/a ffJ m. PO/r .SID' Cross Streetf -5A IC[!'a. Assessors <br /> ��, d✓L City GZip Parcel# /6 Z 0,36Q/ <br /> S.PROPS TY I <br /> owner j r-�Address P0,4bx2OY9 City 5rick Zip(�9r�Srloz.Phorr-- c�,, <br /> CS7 Contractorij u ��,e��s r1-1 City LJL;,�rYic#�0"�°'�hon1A , 3t -54tcQ <br /> Consultant SubCntr Address A• Z3u City,,':j�Lic# Phone# 167-9.33'1369 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> B NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) 1-14j-2-7 <br /> O SOIL BORING# OVER-BORE. DIAMETER <br /> DWELL# ,�PRESSUREGROUT L/ <br /> a*Other •GROUT SPECIFICATIONS <br /> COMMENTS:O, t3 tC•g/oma L-/fir<eno e 4.e/l Aox elrr r er/ec. L'11"A~II i, /l — 3'dee'o' <br /> G. o Cet s�•-� ZcJ , roe-..r SL ^C.Q_. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Cr I/ <br /> B MONITORING B HOLLOW STEM DIA.OF BOREHOLE /0 r 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: / <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESSCS <�j2TYPE OF CASING: O STEEL , PVC BOTHER: <br /> 0 VAPOR B MUD ROTARY DEPTH OF GROUT SEAL ^30 TREMIE TYPE TO BE USED: 0 AUGERS KHOSE <br /> O AIR SPARGE/OZONE O PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes B No (NgOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /o!-TV Lt,-a--•7 <br /> O OTHER:_0 OTHER APPROX.BORING DEPTH O BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR C IN PROPOSED IVd (if YES,list p cificatigns in comment section) <br /> COMMENTS: L/t ifl/ <br /> RS Fru `J - ,.. ,�c7� ,�a.�, `vf-.-r'' /�y[:•r�-�.�,. .5 <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 <br /> Regulations,and all applicable California State Laws. <br /> Signed x // wW Title/Company <br /> Print Name_ nc,,V Date :�rS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORKPLANDATED:''C.1Q2i>(-t_.Cl & ^�yy6 <br /> Application Accepted By ✓` Date Issued 21 LS16� q Area {�_ <br /> Grout Inspection By Date Final Inspection By t Date <br /> Destruction Inspection By <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <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 />