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San Joaquin County <br /> Enviromental Health Department l SITE <br /> �0 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> SITE NAME' 09) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 2 1 2007 Well Permit Application <br /> ENViRNNMEcFTp�H REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is herlt9�drt' in 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 DepartAssessors <br /> /t Cit _Zip Parcel# /E J 03W 2 <br /> WELL Location 35/5' -.,,. n.;..� Cross Street�l{„ �p n � Y <br /> OwOerE7 a / -TY �Address2 IYSs tz ( .-c>L.+.fl`� CilY li`�3o-` Z��i!!P`/�08/o Phone# 707-FS6Y-/6/-1 <br /> 8.795N8Phone# 9/L-63t_S <br /> C-57 Contractors,,, yrJ..t 19Yy9 K,.z/5l d.'�C CA 95Y76 <br /> S__:I,- ��o City i .Lic# Phone#�1a-1 -933-Z36y <br /> Consultant Sub Cntr� 1 = Address <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,KNEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') O DESTRUCTION <br /> .I (choose type below) <br /> DIIAMETER <br /> SOIL BORING# Sg L/- B PRESSURE GROUT <br /> vr�tzr�,M� 2­4 / GROUT SPECIFICATIONS <br /> B <br /> *Other <br /> COMMENTS: <br /> - <br /> COMMENTS:� �r lis -V-3 ty-9 w (t — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS II <br /> B MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: f/D��'25- <br /> U EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS_ <br /> TYPE OF CASING: O STEEL 0 PVC g OTHER:T�f/M( t-1 e <br /> 7[VAPOR p MUD ROTARY DEPTH OF GROUT SEALS, fa51.$ TREMIE TYPE TO B ()E USED: AUGERS p HOSE <br /> D AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL' EPTH IS 3�`c u <br /> SOIL BORING D "� Q 6° <br /> HAND AUGER GROUT SPECIFICATIONS �`+ r'- c OLTED TRAFFIC�OX or 0S�T'OVE IP <br /> B OTHER: OTHER r����� APPROX.BORING DEPTH d- <br /> CONDUCTOR CASING PROPOSED A J lJ (if YES,list specifications in comment secti n) <br /> 1 ��x . <br /> COMMENTS: V I.✓ v. 6� /terf-Cr s �rkcc <br /> etz 3,11 /.-?¢' e' , r�Ge. <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 Laws. �r <br /> Title/Company 41�01-es �✓q,e, /�o1P�"o 1/-/.Y'15Co� <br /> Signed <br /> s � <br /> Print Name Gr c•.1� <br /> DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ( � <br /> WORK PLAN DATED: <br /> il. � Dale Issued '�107 Area <br /> Application Accepted By N ate. <br /> Destruction <br /> Grout Inspection By /LK.�w''�,( Dale y��3:��Final Inspection By <br /> Destruction Inspection By Date <br /> 77COMMENTS I CONDITIONS: JJ\ <br /> Cv <i3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 35'01 F9 2004 l�� III LRO� SR# ITS� 7� c� <br /> uthorization to sign permit_Encroachment doc_ <br /> INSI C-57_ WC=WAIVER_ C-57 Letter of A <br /> EHD 29.02-001 WEB <br /> 9/11/2007 <br /> 1 <br />