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San Joaquin County <br /> Envi>i onmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd 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 /> q�' / Assessors <br /> WELL Location l� G✓��+�/ �� Cross Street City Zip l J��(o gParcell#q ,/ ] <br /> PROPERTY 1 GI t(LOi,hcG��C G� l�G ' ( l�• 7�F�j/ <br /> Owner 1 1�1lAddress 7D 8p,� /1J/ L 1/� Ci Zip l � Phone# <br /> C-57 Contra ctol VJ 60 (/U7u� IC� C 5"� <br /> /' h Address // / ,/C,,i�ty I,./Zip�fyS�Lic#_y85/G�Phone# 2 <br /> Consultant/Sub Cntr Address �`t S 1'eQ)City 04 r+� 4ic# Phone# ��6 z�5 �� <br /> r <br /> GIS Coordinates:X Y Township Range Section <br /> W RK TO BE PERFORMED: <br /> EW WELL/ BORINGOP BE, YD OPUNC AND-AUGER, OTHER) 0 DESTRUCTION (choose type below) <br /> (( \\ 0 SOIL BORING#_ 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: ZIA—?In A C?,�J4.11 tet � �-1 1-111 � �-r-r/�Pi�1 111' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 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 /> -?COIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 'OTHER APPROX. BORING DEPTH 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 Ordinances, Rules and Regulations, and all applicable California State <br /> /Laws. <br /> /� <br /> Signed x / Y� — J Title/Company' V_v <br /> Print Name A)6 t_ Q /l Date U <br /> Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: (L6q 16 o'? <br /> Application Accepted By t Date Issued_ 1 Z_jo5 Area <br /> Grout Inspection By l,� Date t O Final Inspection By Date t 1 6 p <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 /> zfka-V `4 S9.O` o6`(tyc lc( Il}r o`� SR# 519695 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EFID 29-02-001 WEB <br /> 9/11/2007 <br />