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FILE COPY <br /> °'•" '9an Joaquin County I� <br /> Environmental Health Depa1EUEv SITE <br /> 600 East Main Street, Stockton, CA 95202-3��0�299 r MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgM4gghK 2008 <br /> UNIT IV <br /> Well Permit ApplicationENVIRONMENTHEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAYE�S LU SERVICES <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 o/f/San Joaquin County Environmental Health Department, <br /> WELL Location 9351#y 5gnf4 Fe/W Cross Street R' !' Ue City I 'L2t n� Zip S3L T Assessors D / <br /> L_Parcel# <br /> PROPur, - ^ <br /> Owne. _ . y i/ Zip 347Phone# <br /> S Ir <br /> �—f' �� ero 13(vol City�t/kC[0 Zi ;�Li�Phone#Q,�S-S?/-/Yi�O <br /> C-57 Contractor / Ad{dres p /� <br /> Consultant/Sub Cnir O u ' y Apd�d/r�ess6��1/7((jE St" CityLic# — Phone#>(S�d°.�507-/ <br /> GIS Coordinates:X 34• ,Y-120. 1 TO ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEWW LL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> WELL ILBORING#?Sty t". ( � B OVER-BORE. DIAMETER <br /> 0`Other a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE2—_ w 0 MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE )(PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS h Y4 T(e Ott III <br /> 0 OTHER: p OTHER APPROX.BORING DEPTH--$ �,0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ,tom 6 T ND CTOR CARING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �'1'et ry ru ,�iFlv�/'p n U l•L <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 O inanc(e�s, ules and Regulations, and all applicable California State Laws. <br /> Signed Title/Company 6eci C O yt C.O(1S Ul�A4/7 C <br /> Print Name_ 1,21C44Ak 1 t2't SSort Datcitz�?� WOOD <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z35�Y cS 1 Nom` /4p� <br /> WORK PLAN DATED: Z3 2490 <br /> Application Accepted By Date Issued J-'/�4 Area iI ao <br /> 51 <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 CHH�EyyCKK#�# REEC'D,, BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> el Lrj $� : 3li3 �/F Zz47 c.x�� S70• SR# 6)! <br /> C-5 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Ewsaeeehw, it doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />