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*San Joaquin County • <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 />P f< �/Ar/�RC'�lepp LIMP PCDCity _/ g Assessors <br />WELL Location Gross Street / City L y� €N Zip / �ZJ E+ Parcel# ��T T v v2 <br />PROPERTY <br />Owner -rye --'A 0 —1a(Q Address ��lV L City S/ '�ipPhone# --)019 <br />C-57 Contractor � � A�l< </ess'?g w 0'ff e e/� City ~C CZi _Lic# 7�7 �Phhoone# <br />Consultant / Sub Cntr Address City Lic# Phone# <br />2Ny✓ �� <br />GIS Coordinates: X 'Y ,Township Range 9 Section <br />WORK TO BE PERFORMED: <br />EW WELL / BAR416r' (rPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL#20 <br />0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: _ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING / 'gHOLLOW STEM DIA. OF BOREHOLE/ 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING GIA: <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 SEALS€ A✓eZS--TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes No NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER <br />INGpPJP,TCH' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />;ASIING PR ISO �r (if YES, list specifications in comment section) <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 Ordinances, Ru d Regulations, and all applicable California State Laws. <br />Signed Title/Company.rEN/!T Arm <br />Print Name ���f �iL e oWo e4 L Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITI <br />DEPARTMENT USE ONLY <br />Date <br />Date Issued <br />Inspection By <br />NOV 15 2007 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />GHE K4– REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />SR# Z& e3 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EHD 29-02-001 WEB <br />9/11/2007 <br />