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,ora`''" San Joaquin County F I S PY <br /> Envi or omenta' He th Department �` JITE <br /> a: <br /> "•', <br /> ENgP68-3449 <br /> 600 E. Main Street, Stockton, CA 95202-3029MITIGATION <br /> Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT IV <br /> V 0 9 2007 Well Permit Application <br /> ENVIRAMENT HE,01MEFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hP10Q�n00tVM�Q�in County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Develop en'frit e,LTVpter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �/�7 ,//!1 Assessors <br /> WELL Location 72 7 / ¢ el(,6( VCross StreetW�b4/A KA, City 5�'c"Z"I Zip 95-2o Parcel# 0-77g6ojy <br /> PROPER r qq�� 3Z5— <br /> Owner ✓ 0" C" Address 13//6 ✓,q _City�4��,jc 5 ✓ZYp�2�Phone#-'56'Z-92l-3561p3� SS6� <br /> i <br /> C-57 Contractor >� n�r-� �,,,���II ilk• Address/C��i ( ./e!�•; fw? City {.¢ .� Zips-Lic# Phone# <br /> Consultant/Sub Cntr( �ry`'0.O`'r< G�.5ti "Addressg/2 &,15� � city <br /> it (+: �" c� <br /> y `�f Lic# lts-5`5'L(�. Phone# <br /> GIS Coordinates:X alol1O7.37"Al. Y 41g17r,2 q9"W,Township �Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER DESTRUCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE. DIAMETER 0,�'r <br /> a WELL# 0 PRESSURE GROUT L S <br /> 0*Other n tj GRO�Ut,TvSPEiCIiF•+ICAaTwIONS � <br /> COMMENTS: t�k tsvtv`T <br /> ft, eu"f o sv <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING `�tHOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:___ <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC 11 OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS Q HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH g BOLTED TRAFFIC BOX or <br /> a 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 i pplication and that the work will be done in accordance with San Joaquin <br /> County Ordinances J�Ru�je's�and gulations,and all applicable California State Laws. / <br /> Signed x 2 - v Title/Company 6"1-—t:,X 1j jt3i/�/�r cA �M1�cu� <br /> Print Na L Ltf►fihv! d!u Gtl17 Date / / d 1 '°} <br /> DEPARTM NT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued —p Area-'r/ <br /> Grout Inspection By Date Final Inspection By G <br /> Destruction Inspection By Date L <br /> COMMENTS i CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dock <br /> EHID 29-02-001 web <br /> 6/22/04 <br />