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opo"M � Joaquin County <br /> >:�.o ,jiJU � <br /> r. EnvirG. mental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 In P 9 2007 MITIGATION <br /> f <br /> - (209) 468-3449 Fax: (209)468-3433 Web: wwwsjgov org/e a UNIT IV <br /> C' \�.. <br /> 't1r=ORd Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> 3i Application is hereby made to San Joaquin County for a permitto construct and/or install the work described. This application is made in compliance with San <br /> 1 Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. k <br /> S._f L ! � Assessors <br /> ✓2c jCi &, g Zi 3 °Parcel# T! � oto J7 <br /> WELL Location 1/60 1 i S4- �o5a A Cross Streef JAn L a tY p '— <br /> 1 <br /> t PROPERTY �. / _ L��_ d� i <br /> Owner fix- - c Address / ✓ L��r �/��City t., ­nno-bdLip hone# <br /> �2 q 921=.315-cS koc <br /> C-57 Contractor '. / �� Lic#I:> 07Phone# <br /> L Addresses o err...f City.JL-/vet_ �ip9ySS3 <br /> Consultant/Sub Cntr �'''"��`94-��''�� Address gyp.4YpY4. u�rrs:9e O.^ City 27ce,*,mLidi Phone# <br /> II GIS Coordinates:X ,y.,Township _ Range Section <br /> } WORK TO BE PERFORMED: <br /> Ir ,'NEW WELL I BORING (CPT,GEOPROBE.HYDRnPUNCH,HAND-AUGER,OTHER-) p-DESTRUCTION (choose type below)n OVER-BORE. _ <br /> I ,,.grS01L BORING# LST-!j ._� _ ���/L C P n O�� 0 PRESSURE GROUMETER <br /> III a WELL# (V• GROUT SPECIFICATIONS <br /> I a*Other <br /> l COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 a MONITORING p HOLLOW STEM DIA.OF BOREHOLE_2_ 0 MULTIPLE CASINGS ()MULTI-LEVEL WELL CASING DIA: /✓04_ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS A:A TYPE OF CASING: 0 STEEL DPVC OOT ER' ' HOSE . <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEA {{TREMIE TYPE TO BE USED: <br /> .41R SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes o (NOTE: MAXIMUM/ FREE-FALL DEPTH IS 30')' <br /> i ;KSOIL BORING a HAND AUGER GROUT SPECIFICATIONS Po C <br /> 0 OTHER: a OTHER - APPROX.BORING DEPTH G�FE- D BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED✓c7 (if 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 /> County Ordinan s, �ule/s Ind Regulations, and all applicable Californ-a,State Laws. <br /> ? Signed x I ) <br /> n Title/Company <br /> Print Name ✓1 1� �._. - Date "f <br /> DEPARTMENT USE ONLY nn <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 1 L w �D Sem 1�� �S J2n✓e <br /> WORK PLAN DATED:— M" .2 <br /> i l _p <br /> Application Accepted By V '�f, A I- M,4 1 _ Date Issued I) �¢„ 3 h woo Area 1 J I <br /> L <br /> Grout Inspection By ufLrz��'�.CH 7/���14�°.L�7'�4-✓—Date Final Inspection <br /> Destruction Inspection By Date AA - <br /> COMMENTS I CONDITIONS: Ftd JL✓:n r t CPT- [ <br /> l -f- <br /> I ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35 D1 09.06 y Ud OZOO46 `7/112 . 10-31-07 SR# 005246,4' <br /> C-57_ W_-WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/1112007 <br /> i ` <br />