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FILE COPY <br /> q <br /> Joauin Countynu <br /> lECE V SITE <br /> Environmental Health Departma <br /> 600 East Main Street, Stockton, CA 95202-3029y MITIGATION <br /> C P <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.olld2 Q 2008 UNIT IV <br /> 9�rFORa Well Permit Application ENVIRONMENT HEALI O <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUR�IT/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 of San Joaquin County Environmental Health Department. <br /> 3 S6 y S f F Assessors <br /> WELL Location a/I a e Ko( Cross Street Men ve city)et ✓,bt&m.kzip Farceur �y907D/7 <br /> PROPER <br /> Owner %v'DAlm6v131we Address 4/Z2RC'(�&nk1a// n�lty-L�Zip� Phone# 209-871-9v72 <br /> C-57Contractor L//j/'/)e,& Address-25-292 Piehern A46ty e a zip�3Li�5,7- Phone# 2C-_92L1YV)j0 <br /> Consultant/Sub Cntr(rPoinn lO t)k/ L4I Address a ZZ 47sa 5 f C1tyGv,".,,,rr� Lic# — Phone#9.ts-]A'S'S 02/ <br /> GIS Coordinates:X��_'Y-jZI).qq� ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') g DESTRUCTION (choose type below) <br /> /$SOIL BORING# I Z 0 OVER-BORE. DIAMETER <br /> B WELL# PRESSURE GROUT <br /> Q"Other ZUFAiu K ,o�r</i GROUT SPECIFICATIONS <br /> COMMENTS: ./rer, 74 /e horinaw t. .fte a/�/ �,,. r�rel r°irae <br /> . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE g MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA:_ <br /> p EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC p OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS u HOSE <br /> a AIR SPARGE/OZONE VPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> jrSOIL BORING a HAND AUGER GROUT SPECIFICATIONS__ hew- Lr.,.a sY <br /> OTHER: 01redhi k a OTHER APPROX.BORING DEPTH %0 <br /> p BOLTED TRAFFIC BOX or a STOVE PIPE <br /> COMMENTS: 'YA>eMbVYitu. <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> r-�., w ire /blvd row., t <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. /' f �q <br /> Signed /Z / Title/Company 6;06;0C40OCtti `es;pu v�J�ilLvp ,Z`n L <br /> Print Name K/r yAQ,1-W ssC rfi Date <br /> DEPARTMENT USE ONLY <br /> / <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z 356 S 9+� — <br /> WORK PLAN DATED: 23 ?.00 <br /> Application Accepted By Date Issued Area e� <br /> Grout Inspection By Dale 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# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 fp <br /> 3n osL2 3 DI SR# QJ (00 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N1 <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />