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- coc �*w_oan Joaquin County Q �) Environmental Health Department�`•:�-; ( 600 E. Main Street, CA 95202-3029 ui a i!i�,, •. SITE (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.af"/&h 'I; MITIGATION NIT Well Permit Application r`;1.11.' '~ , IV NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. WELL Location Z 2 Z G; to B C A r!�; !A tq .7 c fi c•,U I tj Cross Street S T P,k E rAssessors PROPERTY c A h' TC/? V City 5'T Gr t;lit't�I Zip ✓s�1 G Parcel# i" St'I e c f ¢ (�, f I'� �r 4 Ci Yui Owner L/-C4 Lir I S - c•iyo i?is( Address f�;�?? �. .J�C i,•ct"5 lr;� E:%S, El itis 1:.ES:%;:CE �' CityiC� Cht Zipi� �: C-57 Contractor-11 A' S Ac- I�- ,f i�� Address V.Ci:: L3�E � !? I � Cit Y Lc". f5 Zip:; t (f Lic# EF C�'Phone# (31G - ti- n Consultant I Sub Cntr 1�I�IACr,�: t\ki. I- 5, Nti f;p i�v:' r'-�-ti`:.r k2G 6 `� 1ZIC 1 -------_ ' i Address Wt -,L70 N Lic# y S x Phone#l ,�S J p 23_ GIS Coordinates:X Y Township Range Section WORK TO 8E PERFORMED: Q NEW WELL/BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) 0 SOIL BORING# 0 WELL# 0 OVER-BORE. DIAMETER I*Other if•-I tt •7 k _ t V..-� 0 PRESSURE GROUT GROUT SPECIFICATIONS COMMENTS:_S iArri ti SAMPL. TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z 'r Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS f I A TYPE OF CASING: Q STEEL 0 PVC 0 OTHER: 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ; ► TREMIE TYPE TO BE USED: Q AUGERS Q HOSE 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes S No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS N i`A•l C l_Nit N Q OTHER:_G OTHER APPROX. BDRING DEPTH 5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE CONDUCTOR CASING PROPOSED i°i Gt (if YES,list specifications in comment section) COMMENTS:_t-:ft_M I�C E NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California State Laws. Signed x �� .v,�r _Title/Company I'r�i_S!t7 t'-ti.�J l:A{ Atr c E Nv d tog N M E Print N�m� .F E: 'Ft I;I'a ft t r- Date 1 t Z y C � ._ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: Z2 --L S r A'V en.U e- WORK PLAN DATED: JU kg27 2007 Application Accepted By Y (f"Yty, e V Date IssuedDffAreae Grout Inspection By y i r� i m 2A A' !"'�•rr Date ) Z0,9 Final Inspection By_1fir7Y,'4,MY6 JDateL)_/ Destruction inspection By Date COMMENTS/CONDITIONS: S L V e- S i S V- V-S r AYrI�I�S ACCOUNTING ONLY: AID# FAC# PF CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE 35)t E49. 00 383. 00 �q �a� to -lG-d SR# ()O5- 2297 C-57 WCC WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ EHD 29-02-001 web 6122/04