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2qk c Cl-in Joaquin County <br /> ` Envisimental Health Department SITE <br /> t 600 East Main Street, Stockton, CA 95202-3029 / MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ , �� f5im�� NIT IV <br /> Well Permit Application DEC 7 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS U ,tp�[W z��� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. �cia in compliance with San <br /> Joaquin County Developm le/,t(7��,'apt r 9-rt 5. n the Standards of San Joaquin County Environmenta'I-j��l�''L�A'c�rl�'Ir IT TC 151 <br /> iv "C" • V, 0 tt rr9✓t / ssessors1-51 -20106 <br /> WELL Location� 1025 Li f/,rY • Cross Street City � `cKT•1 Zip gSzoS Parcel# <br /> PROPERTY • ..J- O 'r• Min -5 d / t �/ p 151 "1 0 3 <br /> Owner I C-/DC Ct5� Address 1�00 WVa sp�4NO City S�aC /o/1 Zip / ne# <br /> nccT �1 _ ay9- �-�o <br /> C-57 Contractor RJ1� �fl llr�g Address dao N'��s� st' City1.(�o—' Zip /��Li� 8�3Ph6ne# 590-doel <br /> Consultant/Sub Cntrrca-jor 4tUirc.kAddrersls tq@ Fi- ,. I✓tsrcr ity IDe4f Lic# Phone# <br /> b <br /> GIS Coordinates:X 3 3 /f3q1 ✓ ,Y Z17 I ZI / Township _Range�2 L Section <br /> WORK TO BE PERF <br /> D NEW WEL /L BORING (CPT, EO B YDROPUNC_ AND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> D SOIL — D OVER-BORE. DIAMETER <br /> 0 WELL# D PRESSURE GROUT <br /> D*O_��t//heer�r GROUT SPECIFICATIONS <br /> COMMENT64A \Ivc'rrr 5�lil s Nill bLLallc het <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS .HOSE <br /> D AIR SPARGE/OZONEPUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes ,g,Ao (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER:_0 OTHER APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or D 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 Ordi artCe , Rules an egulations, and all Plicable California State Laws. <br /> Signedx / Title/Company .�.G- <br /> Print N <br /> DEPARTMENT USE ONL��YLL <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /UZS f< i(ka (I-OClL7� T'-5A <br /> WORK PLAN DATED: /�//I,12(a 10) <br /> Application Accepted By f�wy ttu Date Issued 7 AreaJ29 <br /> Grout Inspection By to 11110-" Date / 1 a7 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS]CONDITIONS: 2&6- <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED FCHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> l(o ,-z ��,�_ SR# S-Z82.S <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 />