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San Joaquin County <br />Environmental Health De artt4�' rrg- E DD SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov�,9rgZeM 3 2008 UNIT IV <br />Well Permit Application IF ,I�;�;i-f1T HLALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1fSb iiT'S;FPV!GFS <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 />WELL Location ,�t7� 11� k;�Q Cross Street City % �ccc' Zip�� � Pacel# Assessors M -� O 07� <br />PROPER` ! ��)Alw�+Hc b:i :Si�w twi�C 4cti::s P r1533�' 2a`i ZS C e <br />Owner_ _Address" _City_ _Zip _Phone#_ <br />C-57 ContractorVkyi,�" Aim � �-i'�L" Address 1-3;, 7,0-ctr, zLAP City i 6 `A Zip Lic#-Z « Phone# :7-0""l <br />S4 iq_S--t "A -40 -ill <br />Consultant/ Sub Cntrs--t1, ,"—sAddress CTGAn1*,e; %j 1 ,s1._ City f 4f -i- Lic# Phone# "Z� 6_40_ (11--Cq <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />�.�NEW WELL/ BORING <br />0 SOIL BORIr <br />IJPINELL #_ <br />0 *Other <br />COMMENTS: <br />Y <br />Townshi <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />2— :m.w —3 <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />FEE INFO <br />MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />DATE <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />_74_ <br />CASING THICKNESS82ic40 NC -TYPE OF CASING: 0 STEEL *_PVC 0 OTHER: <br />. <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL o7-! TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />� ?� 0� <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOT : MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH °BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />r <br />Signed x40�-Title/CompanytlSi <br />Print Name Qyll�tsDate_ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:-- -� is <br />WORK PLAN DATED: 11 1.30 1b / <br />Application Accepted By Date Issued U Area ! r <br />Grout Inspection By �rn Date q -i Z� Q Final Inspection By Date `t S <br />Destruction Inspection By U Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# �p5` <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMI <br />INVOICE <br />3 5-o a <br />s L1 <br />$ <br />�- <br />`7V1�- <br />� ?� 0� <br />sR# 53 °1 <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 />