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-j1r <br />, ,an Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ,1�/I� MITIGATION(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/chd ✓ <br />Well Permit Application [AAR 2 2007 V0 U11 w141M, <br />A L <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 />FEE INFO <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />CHECK # REC'D BY DATE <br />Assessors rt <br />2771 E. FRENCH CAMP ROAD �� ) d 0,25 <br />INVOICE <br />WELL Location Cross Street City MANTECA Zip 95336 Parcel# / <br />60 <br />PROPERTY 2771 E. FRENCH CAMP RD (209)982-5691 <br />Owner DEAN JANSSEN Address City MANTECA Zip 9S l-�6 Phone# <br />ADVANCED GEOENVIRONMENTA" 680227 (209)467-1006 <br />C-57 Contractor Address 837 SHAW RD. CitySTOCKTON Zip9S21S Lic# Phone# <br />ADVANCED GEOENV--RONMENTAL <br />Consultant / Sub Cntr Address 837 SHAW RD. CitySTOCKTON Lic# 680227 Phone# (209) 467-1006 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />g NEW WELL / BORING (CPT, GEOPROBE, HYDROPU NCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />D;SOIL BORING # SV -1 , SV -2 , SV -3 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 `Other GROUT SPECIFICATIONS <br />COMMENTS: <br />Q\ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1. 25 "[] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ______ <br />?� <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 a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />� <br />EtSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 5' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: PLEASE REFER TO WORK PLAN DATED FEBRUARY 27 2007. <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 />Signed x fes^ L�� � Title/Company STAFF SC--ENT--ST <br />f <br />Print Name BECKY LEE Date 03-21-2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2-77/ E. r►"B n <br />WORK PLAN DATED:Fe brt,1y r,4 27, 20077 <br />Applicat;on Accepted By V1 C-11 D,, r+ L M� lCl YT1L�C t Date Issued Z b % Area <br />Grout Inspection By �' I C` U-eA is Cgor-i7La4- Date Final Inspection By Vi i l Ct Date 0 7 <br />Destruction Inspection By qq yDate <br />COMMENTS/CONDITIONS: ttGiVrYYIL'eYYt_PrV + !1 -I <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />563 <br />60 <br />374. co <br />SR# 005-000 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />