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� i fU) <br /> z San Joaquin County �}L 1! Q-JIL E COPY <br /> �Q ' Environmental Health Department <br /> 600 East Main Street, Stockton, CA 95202-3029 kiAY 2 Q 208 SITE <br /> (209)468-3449 Fax: (209)468-3433 Web: wwws' ov MITIGATION <br /> �� �'1NMENT 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 an 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 /> WELL Location 66 cj SOel <br /> Cross Street l4eftill Cit /`rv-4 Assessor <br /> W <br /> PROPE /' y ak Zlp 'M 7 ParcelQ e <br /> OwneriJTY )kIf/j Address,0ty/ /-/OI7/10/IIQ� D( Ci(y/itt�PS`D Zi c� <br /> C-57 Contractor Addres P +JSlI Phone#�-303- 1-S r—� <br /> /� — S1o2 9.��//ir.o B/y� city //e zip[�y�S�l;c# <br /> Consultant/Sub CntrG Phone# �/ -_4;a(/-/ (/ <br /> YO"M 6pf0/ : r Address"r/derySa C-f 1yy��0, <br /> GIS Coordinates:X l��City—"'"LIQ Phone# <br /> 3 . 35 Y-tzo.� Fa — - �'' svz� <br /> Township Range <br /> WORK TO BE PERFORMED: Section <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER.OTHER') 0 DESTRUCTION (choose type below) <br /> rQ"SOIL BORING# /�/ <br /> DWELL# DOVER-BORE. DIAMETER <br /> 0*Other 0 PRESSURE GROUT <br /> COMMENTS: /'r� GROUT SPECIFICATIONS <br /> p ']�/KIP. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEZ-Ly- 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ----- <br /> 0 VAPOR TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. <br /> �!0 AIR SPARGE/OZONE t,0'�USH POINT(GP or CPT)GROUT SEAL PUMPED: (,NOTE., 0 AUGERS 0 HOSE <br /> 4l"50ll BORING p Yes p No MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 HAND AUGER GROUT SPECIFICATIONS M6� <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH <br /> Yd 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �t/ /r�'1(, m'4!CONDUCTOR CASING/� �n unC PROPOSED (if YES,list specifications in comment section) <br /> ]� <br /> Or <br /> COMMENTS:! __#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, ules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company t� ItC 0 0/6r? <br /> T <br /> /15A�rtf <br /> Print Name s <br /> Date <br /> DEPARTMENT USE ONLY / J <br /> SITE MAP IN UNIT IV FILE,ADDRES �/3SIn9JEW NOn <br /> WORK PLAN DATED: <br /> Application Accepted By. <br /> Grout Inspection By Final Inspection By Date Issued_ Area O <br /> Daf <br /> Destruction Inspection By Date <br /> Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* <br /> RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Qq '� �v2 22 &-2 0(Y <br /> C-57-%/ W —WAIVER_ C- Letter of Authorization to sign permit <br /> EHD29-02-001 WEB _ <br /> ochment doc <br /> 9/11/2007 u-C'u <br /> ,tc� 3� <br /> S <br />