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EHD 29-01 11/5/07 (WEB) <br />O 69 illtc -/ittra <br />/0&.? <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT III, siTE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.siqov.o/hd UNIT 11/ <br />WELL PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDENVIR OW'f±"' <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 <br />Well Location 512 Cross Street OVER- ke1.5efi City .3TO LAcr tj <br />Assessor's <br />Zip .S.-c? IS- Parcel # 0E34 - t -Cc} Property <br />Owner 5AvA OR-t..454-1b0 Address q-1'26- (9Av-Litt-be City T.--TD c) Zip `7S-011.3 Phone #..5 - <br />C-57 Contractor 50iL-i-Ja-VE.g." WC- Address i 2_5.' ;-... 1 • t.iA•i;e2s; ti City Lic # 13R' 0 ?4S-Phone 53-5-7443:-.) <br />Consultant/Sub Cntr 5PC, Address 5-040 r--i. 1'4.77( 5 City Cityf'737--E7-5frik9 Lic #05--d6 s3 Phone -5--- - dd5 - Vs" t <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: „.---''-'7Th <br />14 NEW WELL/BORING (CPT, GEOPROBV HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (CHOOSE TYPE BELOW) I:I SOIL BORING# -c-' ;%-c-iferr14 S - D OVER-BORE DIAMETER <br />0 WELL # 1:1 PRESSURE GROUT o *OTHER GROUT SPECIFICATIONS <br />COMMENTS: 'e GS. 1,‘ LAT,E rgori-,Aitt s: <br />TYPE OF OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE a. s " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ..----' TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br />0 AIR SPARGE/OZONE gl PUSH POINT P/OR CPT) GROUT SEAL PUMPED: 0 Yes 'No INnTF. MAXIMUM FREE-FALL DEPTH IS 30') <br />Ar'SOIL BORING 0 HAND AUGER GROUT SPECIFICATION -g....777:Wi7C; c-itg3i fi7?..- I 0 0.(FF td,4,1 EV( nr:— 61(AS.Pk-ar <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH d 6 d5 ' ; 6 ' 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING FROPpSED if YES, list specIficatons in coinment section) <br />COMMENTS: Explark-ivry b_orirkis Knik.si- 6_, yaii-r-44.- ...14 -----be.e...-1-Ark ,-fre Or c. e...1A.e..4 ' 5(4‘rrilrocal-.. <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 pplication and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicablCJ.for i‘ Laws. <br />.00"7 <br />Print Name <br />County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Signed Title/Company '7,st 0,J01-7- 41-447j, iL; Alp+ /16: <br /> Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DEPARTMENT USE USE ONLY <br />,5C 1/ <br />FINAL INSPECTION BY t DATE Zit 3-/C>ff <br />DATE ISSUED //d- AREA <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: 48 ablep.e -AC-$ alert 4.; rev' e tri 415 fo-ing7L- Dr //15,ec776-at be re__1 (e_s py t _ r-4 e_f -( p4(.. ,Set_c_ondrhon.s above-4r rou -brt . <br />ACCOUNTING ONLY: <br />(1 (i <br />AID # <br />.1 C. / <br />FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br />4-4V4- in i /7 I 1.6 -2 7 -2-1) //9-FAI ? SR# 54-`071 I133'30 <br />DATE <br />0 SIGN PERMIT <br /> <br />ENCROACHMENT DOC <br /> <br />Cird/b2_, Cie/IC.4' / WELL PERMIT APP <br />(rliT7(7 (1,e--e45744—,L41(gri