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FILE Copy— <br /> qurnr San Joaqxdn County <br /> JUN 1 P 2008 'artment SITE <br /> nvironmental Health Dep <br /> in aV), .1 ENV1R0NMbN1b1fMTh1 street, Stockton,CA 95202-3029 MITIGATION <br /> PE9MW5&RV0Tax: (209)468-3433 Web:www:Sjgov.org/ehd Sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> 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 /> 115,3 and the Stan <br /> Joaquin County Development Title,Chapter 9-1 dards of San Joaq.uln County Environmental Health Departrrrent. <br /> Assessors <br /> Crassi Cl� 5-b:I��-Zfp <br /> WELI-Location Stnet <br /> PROPERTY 'a C- zip aVg-Lt_j_Phone#_3]QL4 Z <br /> Owner-C!pn&j_)a--5 a_�U�SR Address City 0 - - r <br /> /I Ka2^CAAQ <br /> C-57 Contractor CangNIF_ JV�V1 0 Ct 'Address'� rtej — ('0�- <br /> �A,Z A, ;1 9 • 'City oe#h <br /> ,j V,, <br /> Consultant/Sub ntra& Lrvso Address <br /> .5j-lie-iIt <br /> Section— <br /> j Z � Township Range <br /> GIs Cot. 9 y=- <br /> WORK TO BE PERFORMED: <br /> INEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') -.8 DESTRUCTION (choose type below) <br /> SOIL BORING#AEL--a OVER-BORE, D1AMETER_--------�— <br /> I . 1M-J-5 1]0 PRESSURE GROUT <br /> IWELL# MW j2d(A) <br /> [I'Other GROUT SPECIFICATIONS— <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> III MONITORING HOLLOW STEM DIA.':OF BORFHOLE�— a MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASINO: 13 STEEL B PVC []OTHER: <br /> Q . TREMIE TYPE TO BE USED: jAUGERS a HOSE <br /> 0 VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL <br /> .1 a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ©Yes <br /> SOIL BORING OHAND AUGER GROUT SPECIFICATIONS <br /> `�Q` a BOLTED TRAFFIC OTHER: OTHER_ APPROX.BORING DEPTH - T5 ICBOX or USTOVE PIPE <br /> CONDUCTOR CASING PROPOSED YES,list specifications in comment section) <br /> COMMENTS-. <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 /> s, Rules and ` d all applicable California State Laws. <br /> County Ordinance e ulations,an <br /> T (2�n5u Eklv,-L r),eJA-a� Oto Y)sQ[+an+ <br /> Signed x itlelCOMPanY— <br /> Print Name E(-;(- OC-6 I bf AQ EllDate <br /> DEPARTMENT USE ONLY <br /> /374) <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> ii WORK PLAN DATED: _p " <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: Alb# FAC# <br /> PE CODES FFE INFO AMOUNT REMITTED CHECK 0 REC'DBY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 'R# <br /> C-57—Z WC✓-WAIVER— C-57 Letter.of Auth6rizatipirt to sign permits Encroachment doc <br /> ERD29-02-001 WEB <br /> 9/11/2007 <br />