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San Joaquin County <br /> N x� Enviomental Health Departm SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CAD MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd �� <br /> r `I' C)Ft P Well Permit Application JIJN 0 1 2007 UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATA3"NMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work des ri . h 3 i ��Qkis 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 2122. S• g;rl crF 10a Cross Street E,g-&34 City NWk:brn Zip 952o(c Parcel# I�9-Iie2 of <br /> PROPERTY <br /> Owner 'RoAVri L-ee lAMAt Address 22o'3 S. R\rncc•1 W +.d City gkrc'Ac rah Zip 5 DU Phone# LUq-yCr25371 <br /> C-57 Contractor_R11 4Ut11 Nh6odonranl- Address_5bQ9 Vl(aGill Vollel.j Rci City ploaru i I le Zip qZ(-1 Lic# Phone# 5.30-00yLi -1122 <br /> Consultant/Sub Cntr A0Vc4ncect &c r r j,(mmen k(Address �Ssl Svtej w Qct City s}nc,k1, Lic#_LSD2a-1 Phone# OL)q- 9u-i- ibbt, <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> JEWELL#_Mtl; y+ gnu S� MVU--LF 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 'HOLLOW STEM DIA.OF BOREHOLE .2j° 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL VPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2(p' TREMIE TYPE TO BE USED: S'AUGERS $HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS p2 11-11 -Poy Icancl N a-1 (2emeR� <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 56 h-�A 0 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 Of nce Rules and Regulations, and all applicable California State Laws. <br /> Signed x_ Title/Company vice 1Wesi''len� .1IgclWmed Gen m/,ywn1enlat <br /> Print Name 00L Date U 1 dun 2 oo l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 12- z r"ilnA.�w� IA)an=2 FILE CPLAN DATED: 3 17 <br /> Application Accepted By Date Issued=61110 Area <br /> Grout Inspection By Date d Final Inspection By /��l�n�� Date yc <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 so Z573�s1 !� b���a} SR# 5 ogzI <br /> ags,oa <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 />