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San Joaquin County <br /> Env><r unmental Health Department SITE <br /> ! 01 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br /> � UNIT IV <br /> Well Permit Application <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 /> /� <br /> WELL Locatio G _Cross Street�l//��r�Gt/4 �4 Assessors <br /> ty Zip_ �G!/ Parcel# <br /> PROPERT� �/ r I� u cc // // / <br /> Owner fi G Address {2.�L460ad�S ''�C;ity S` '��[ ZiprIS2O - Phone#Z-02-13�-a-3a <br /> Q'4C-57 Contractor Y>0 X, �l h Address j/'5 Q ( �/ City RAI-/ K''I- Zip`445" Lic#+"IK Phone# 7 Zr, 3J 3'�� <br /> Consultant/Sub Cntr ��U�/J1 P L Address05 / J�[Q -4�ij oGtf'61+Q�Lic# Phone#-5��/ 2V5 > 60 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/ BORING CP ,GEOPROBEDROPUNCH HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# ) 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC TIONS !U IA- <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <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 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORINQ 0 HAND AUGER GROUT SPECIFICATIONS <br /> VTHERC 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> f CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: N(-M A- �'pn,�,. �..^� � ���C�c�ii�i�. <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 Title/Company .YifdZ'u' GAG is �ZO <br /> Print Name xd4zz Daie <br /> DEPARTMENT USE ONLY IL <br /> Cc? <br /> y <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 9 J6 a <br /> Application Accepted By Date Issued I2 Area <br /> Grout Inspection By Final Inspection By Date I 1 (a _ <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 /> co 06y l4( a I llz'D� S R# 5 8 <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 />