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'FcavrE[JWELL0ERMIT APPLICATION ROM SITE <br /> SAN JOAQUIN r. UNTY MITIGATION <br /> ENVIRONMENTAL HEALTH IYEIPARTMENT (EHD) <br /> JUN 12? 2007 NIT IV <br /> 304 E. Weber, Third Floor, .Stockton CA., 95202 <br /> r inn <br /> ENVIRONMENT HEALTH (209) 468-3449 f�Q/�r 'fV� <br /> PERMIT/SERVICES 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> I �gc?r� ply Assessors IINZ-? <br /> WELL Location d4 f8yqk S+' Cross Street f,1b� 5f. City �1 Zip C20 Parcel# 1 7 J <br /> OwnerPROP �Y 1 6(61+Dgss 177 1 0 ! j'1J5 5� CC/may <br /> Owner L��t 9lt/ 7 WAD LU—V Address Z7o'1 I-z Frfmo.�l Sl', Fl1�City D Zip yy Phone# 7 J Jib <br /> C-57 Contractor (1va ! IIiw ID Address Kim Kim _City Rio Vi Zip/> Lic# 10 Phone# k)?-37Y- <br /> Consultant/ <br /> UJ'.37y <br /> Consultant/Sub Cntr5-J43 5d(yA + Addr3 3�CamannPwlc Ap.�5clty_WU4�Llc4 (4 ?56jZ Phone#530-(076-�7 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. <br /> DIAMETER <br /> 1kWELL# j%W-IS.MW-2;&E-3S� A9W-4Sj MW-ID aPRESSURE GROUT <br /> 0*Other GROUT <br /> SPECIFICATIONS - <br /> COMMENTS: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM _ DIA.OF BOREHOLE t�qftMULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA-,21) <br /> .ii <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING: 0 STEEL )(PVC 0 OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL b$ 15r TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes- r0 No (MOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS fIgRA(1d1L.tT <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH- QG/ VOLTED 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 /> 46 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 Ord' a�nn/ces ules and Regulations, and all applicable California State Laws. <br /> 7 <br /> Signed x )60a Title/Company /-ia•G. 4 !7`17! ,//5 1Ya/�S�f✓iia') /Yt�+r , <br /> Print Name . o Y Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DDRESS: g E 3S2(o`l✓ �� t D <br /> WORK PLAN DATED: 26 <br /> Application Accepted By Date Issued {r7 Z 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 I SERVICE REQUEST# INVOICE <br /> /319 6-lL-q� SR# Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 4 <br /> EHD 29-02-001 <br /> 622/04 <br />