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C <br /> ' c San Joaquin County w � vIECEED <br /> Environmental Health Department APR _ 9 2010 SITE <br /> 600 E.Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov6NW4R%MEPIT HEALTH UNIT IV <br /> Well Permit Application PERMIT/SERVICES <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 Development Title,Chapter 9-11(15.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location Z 5OD NGL✓,i D/'i ✓Across Street B Lev, I Assessors Slaclnton Zp �57�6 Parce# 1621y001 <br /> PROPERTY �pVIA i(./pI 11r'I.Pibs Veil,r <br /> Owner n,y 1 sroc G;A Address .Afle tf K,Md,e CityZip Phone# q 937- 07.3y <br /> C-57 Contractor PTO-C cS;t A SArV LA%cldress 2365 W;Q.,,. eh City�T Zip 5LIc#636)Y7Phone# L09 y65717— <br /> Consultant/ <br /> IZConsultant/Sub Cntr Con J or£.;r rr0 A Address 189 Fi>,nit lv<.,tCf• city SY Liao[ Phone#209 /L73 4-05)A <br /> _ GIS Coordinates:X X3191 Z .a I ,Y Z167-700,19 ,Township 1/10/ 6 <br /> Range L Section I A f 1 7 <br /> WORK TO BE PERFORMED: <br /> ,WEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose ly e� yelgw) / <br /> 0 SOIL BORING# OVER-BORE. DIAMETER r1 cc <br /> k*ELL#�4 Item ILS vy1S M1AW1 j,l to S aPRESSURE GROUT <br /> _dd Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICA O S L� <br /> �1GONITORING ,HOLLOW STEM DIA.OF BOREHOLE O 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_1-- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -leN NO TYPE OF CASING: a STEEL , PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7 2 ^'WJITREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS Vf 1b /s—(04,1 to t eAA-UW -1 — <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH 19 I4 ST-'bt S 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 Regulati ns and all applicable California State Laws. <br /> Signed x Title/Company 45 5 n q D / <br /> Print Name i 1 G 0 Date //Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7-5M 11611 !M ID rA <br /> WORK PLAN DATED: -3. 04 / <br /> Appliratlon Accepted By 11�k Date Issued (� �(� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -Ao1- b4,0J V1.Ia '> 1-L Vv LJ-JAli Ia to SR# 5,1-1_41 <br /> C-571,-- WC_-WAIVER_ C-57 Letter of Authorization to sign permit4.,t-fnncroachment doc_ <br /> EBD 29-02-001 web <br /> 6/12/04 <br /> r <br />