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Hn-Frw5vsAN JOAQUIN COUNTY <br />'ENVIRONMENTAL HEALTH DEPARTMENT <br />UL 4 : tit ast Main Street, Stockton, CA 95202-3029 <br />elep one: ( I ) 468-3449 Fax: (209) 468-3433 Web: www.siciov.orWehd <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />ENVIRONMENT HEALTH <br />PERIVIIT/SFRVICWELL PERMIT APPLICATION <br /> <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 />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Zip <br /> GI 3. <br /> 8 :7 Parcel <br />Assessor's t ..))4 I _3 1_0 itg <br />Well Location e;((tgo tlif...1.2.1ta, aiabss Street PII/C 6.0"-40v4-, City rh r '44 C et <br />City <br />Property <br />y C P Owner C. i - <br />, <br />Ili df ri^ )a --rec r-1 Address i 0 1/ I • (ep,tti- 4 Zip 9 C3 3 -7 Phone # <br /> <br />. 1 <br />rn P44---e <br />C-57 Contractor f\I f s. ) 4-oirrSk,"1 Address le)-- T—J lisTr i w l City Lee) Zipl If0 Lic # 6 Phone <br />Consultant/Sub Cntr 'L(1 A.r-s)Cfr5(w Pj Address ef 0 t)-- .1.1--d t-4-s1r-.) v4) Id 1.-.) ‘ ' <br /> <br />7 City <br /> <br />Lic #Moo l'i Phone L"1 --'?e7 -3.)6 ) <br />WORK TO BE PERFORMED: 74 NEW WELL/BORING (CPTi GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />121 SOIL BORING# <br />VI WELL # Or- - <br />ID *OTHER <br />I=) DESTRUCTION (CHOOSE TYPE BELOW) <br />P OVER-BORE DIAMETER <br />El PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />, e , Z -AP <br />GIS Coordinates:S / 3, (-27, -1 Il 0 i ° Township Range Section <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />yr•Pi <br />l * ' ' jii 0 N IT °RING HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ` <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS rtiC S A 1116 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL p • TREMIE TYPE TO BE USED iiil AUGERS D HOSE <br />0 AIR SPARGE/OZONE 0 PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: 0 Yes fj No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS i b ''.., i, 7 9,, )),.-4 <br />ID OTHER: 0 OTHER: APPROX. BORING DEPTH 3 0" 0 BOLTED TRAFFIC BOX OR ,It STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list spedfications 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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, a II appli le California Laws. <br />Signed <br />T a , Title/Company A)P 2 ) 0 <br />Print Name <br /> <br />Date -V) 1//11)6 <br />DEPARTMENT USE USE ONLY <br />SITE MAP IN tJNIT IV FILE ADDRESS: 01$15-6 <br /> <br />2A,v-af CILL'e--. <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY ,i—j_Llet.1-1 DATE ISSUED //i t/p AREA q <br />GROUT INSPECTION BY 7c.) FINAL INSPECTION BY _1/i 610 ' _.61..gtPATE 7 <br />DESTRUCTION INSPECTION BY DATE . <br />COMMENTS/CONDITIONS: Silt ...e afri4:4.44 /44 4.ti ,4 el 0.44-L - ' <br />. 1 , <br />til.1-z<a 6 r,4- ,, /74. <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE i PERMIT/SERVICE # INVOICE <br />0147= 0 i .3 q '- ft 1 - r).Y/i,?-1/ kk---- ri/iV/42 s R# co; lia'ao <br />C-57 WC -WAIVER C57 LETTIR OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 11/5/07 WELL PERMIT APP