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San Joaquin County <br />Environmental Health DepartmenP SITE <br />600 East Main Street, Stockton, CA 95202-3029 L� 0 7 2007MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application ENVIRUNMENT HEAT <br />PERMIT/SERVICES <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 />Assessors <br />WELL Location 2096 d_-, ST. Cross Street W A _fT'SS City S`%l<TbA/ Zip Parcel# 153 -13 -00 <br />PROPERTY <br />Owner 131U + LJEei),y J—/' 96 ANCAAddress 7015 NOA70AJ 0001 7 City S%CKTo//J Zip S�19 Phone# <br />PE CODES <br />C-57 Contractor �7 RC--C7G D Je440A1q ddress ?-To MOW G R 0A"I City J}LT /VEZZip/gJ/Cy3Lic# '6`- tl� Phone#9�l313 S-yw <br />AMOUNT REMITTED <br />Consultant/ Sub Cntr 147L /}SSaCyA-rCS Address 1117 LONC- ?/;401 9VCity R016STc6 Lic# Phone# .r29.za zi <br />REC'D BY <br />GIS Coordinates: X 'Y Township Range Section <br />PERMIT / SERVICE REQUEST # <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # M W I C. IY1 W 19 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />B- 0NITORING R-1 OLLOW STEM DIA. OF BOREHOLE /0" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 96-N qO TYPE OF CASING: 0 STEEL R -PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 77 t 8'Z' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />N <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: g' 'es 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />O <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 604- 90 OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />N <br />COMMENTS: tC z_6A To A-rCs S�16 Sd�t�1}cC /�11/ES Tr ,¢Ti,�•l L✓oLKPtA�✓ 2eq-r(51) /0Z--1 7 <br />Q <br />a' <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />(C <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin .n <br />County Ordinances Rules 4hd X4gulations, and all applicable California State Laws. �T <br />Signed Title/Company ���r ESS/oN AL o �S 7 fi7G �SibG �t>fs <br />Print Name/ o �/� f �� Date Z o <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: S+ , `I' <br />WORK PLAN DATED: )��6 -:1— <br />Application Accepted By L(j',�AAO,,\ Date Issued Z O tC Area L t <br />Grout Inspection By (� �nnn_c�.. Date 4e6 (01K Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit <br />EHD 29-02-001 WEB <br />9/11/2007 <br />Encroachment doc <br />