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SEP -24-2007 MON 02:17 PM GEOMATRIX CONSULTANTS FAX NO. 559 264 7431 P, 02 <br />San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Pax: (209) 468-3433 Web: w%-w,sjgov.orgfehd <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. 1 2 -4 21 11 5 - <br />Assessors 1 I ':� 0 q o01 <br />WELL Location ..2 To 1 W Cross Street city 4t, tki7 - zip Parcel# j.t � <br />PROPERTY 12 53 60 32 <br />Owner 172:iL r LLCAddress 1313 Z>7. �rhwan6L city > , ' zip 5zo�Phone# 9�! -3555 1 a3 e 13 <br />C-67 Contractor �PAgzz&Wj? Address Clty�i�G"» sj�Zip Sa Lim 63 Phone# !D 5.7 <br />Consultant / Sub Cntr- Address 12�i l; clCcl.✓lrr�. City Llc#__N�_,Phone# 559-26y--2535 <br />/v1 <br />GIs Coordinates: X Y ownshlp Range Section <br />WORK TO BE PERFORMED' <br />p NEW WELL / BORING (CPT G OP.FCUR HYDROPUNCH, HAND -AUGER, OTHER") n DESTRUCTION (Choose type below) <br />Q SOIL BORING # 3 Qq 0 OVER -BORE. DIAMETER <br />WELL # Q PRESSURE GROUT <br />o 'Other <br />G t.^.UT SPECIFIC.�T1^t!5 <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT O S <br />a MONITORING 11 HCLLOW STEM DIA. OF BOREHOLi=� a MULTIPLE CASINGS q MULTI•LEVFL WELL CASING DIA: <br />0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS— ,, ,QQ,,,,T��Y��PE OF CASING: O STEEL Q PVC 0 OTHER: <br />Q VAPOR MUD ROTARY DEPTH OF GROUT SEAL � �." TRFMIE TYPE TO DE USED. o AUGERS HOSE <br />j!IR SPARGE/ OZONE a PUSH POINT (GP or CPT)GRCUT SEAL PUMPED: Yes jj No (NOT/=: 'lUTAXI111111UM FREE -FALL- DEPTHE RI W; <br />p HAND AUGER GROUT SPECIFICATIONS - y' y �4�fht °'t I`�� <br />p <br />OTHER:_9 OTHERIb APPROX. BORING DFPTH�14- p BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSEDIf YES, list specifications in comment section) <br />COMMENTS: l <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 Regulatlons, and all applicable California State Laws. <br />Signed <br />Print Nam <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, A <br />WORK PLAN DATED: <br />Application Accepted By ,,.t %. Date Issued I Z� Area <br />Grout Inspection Dy "1✓ k�a 2�QI6—FIna1 Inspection 8y l+> l -' l Date <br />Destructlon Inspection By Date <br />COMMENTS 1 CONDITIONS: _ <br />ACCOUNTING ONLY: I AID# <br />FA.C# <br />PI= CODES FFE INFO AMOUNT REMITTED CHECK # REC'D 13Y DATE <br />rivn�n''-:r <br />'l a. O% <br />C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit <br />EI -1D 29-02-001 WEB <br />9/11/2007 <br />S R# A2S2o-:A <br />INVOICE <br />0 <br />