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R LAE ov,JD ILE COPY <br /> San Joaquin County <br /> SITE <br /> Environmental Health Department MAY 2 0 2008 <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov-ft1 AMNMENT HEALTH UNIT IV <br /> Well Permit Application PERMIT/SERVIC�c <br /> L/FOR DJC/// <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /fow <br /> K/ <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 /> JoaquinDevelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartmentAssessor <br /> Cou <br /> iO t 5. f� R.1Cross Street�City�/✓ Zip9.r 1Lr Parcel# <br /> WELL Location <br /> OwOe ERN �C Addressa& City ✓ Zip Phonee#��7' 86/��✓28 <br /> C-57 contractor t�/ro/f e X Address 0799 Pni/r.in 8/vtd/ CityLLL[1 " Zi 1 ci.*7 AQZ- hone#yZS�SZ/"'� 1 <br /> Consultant/Sub Cntr&CCAnCoASoI{+fY�t,j,'�,Address <br /> [t➢/ Ons4 Sf CityLVftigwLie# Phone#qa Z' �8S—f02y <br /> GIS Coordinates:X —� <br /> y✓�'Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') <br /> dO CTI ( <br /> (choose type below) <br /> KSOILBORING# OVER-BORE. D <br /> a WEUL# a PRESSURE GROUT� <br /> GROUT SPECIFICATIONS <br /> Il-Other --// <br /> COMMENTS: T/WA4- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIIF�ICATIONS <br /> ULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 " I] <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> AIR SPARGE/OZONE JlPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS hPd f GC�71y°nf <br /> OTHER APPROX.BORING DEPTH XO UBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER:_0 f YES,list specifications in comment section) <br /> �� CONDUCTOR CASING PROPOSED (i <br /> COMMENTS: 1M``D <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. '-/� 1 <br /> /�� / ii�„isnn� Title/Company (j�OCe n G/15V/"/Gn i> 1 ZnC <br /> Signed x ��. -- r-j <br /> Print Name / ?t Ghc t'LJ <br /> DEPARTMENT USE ONL � <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z3 li/g( <br /> WORK PLAN DATED: jj� /'�/ <br /> Date Issued (P Area <br /> Application Accepted By Date <br /> Grout Inspection By Date Final Inspection By <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 /> W— <br /> � Ole <br /> C-57 WC=WAIVER_ C-57 Letter o Authorization to sign permit_Encroachment doc'• <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />