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• F70S 7, CID <br /> San Joaquin County <br /> Environmental Health Department ;:; SITE <br /> w 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/Oid UNIT IV <br /> 4 rF 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 <br /> Joaquin County Development Title, <br /> �Chapter 9-1115.3 andthe Standards San Joaquin County Environmental <br /> Health Department.AssessorsA.I <br /> WELL Location l ZV Yv^ tC C s Street Cityr�ku r"n Zip �U Parcel# <br /> PROPERTY `5`-J Ca Pa I C-Wo <<S c v� <br /> Owner C;lb 1`n nj�/'t^� Address I 1y �2c��yD City S'I'n c-1�"�3�ip � �� Pho�n(ee#-��� <br /> C-57 Contractor <br /> k�d � Address`f.r�� V Hf`CityC .7Zip c Lic#]G r Phone# fit �7� —1 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) I]GESTVERRU-BORE. DIAMETER(choose type below) <br /> []SOIL BORING# o PRESSURE GROUT �L <br /> []WELL# �� GROUT SPECIFICATION ZE/'0 1, /✓ <br /> []-Others I <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS WELL CASING DIA: y 7 <br /> ❑MONITORING p HOLLOW STEM DIA.OF BOREHOLE ' p MULTIPLE CASINGS []MULTI-LEVEL _ <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS, c� TYPE OF CASING: []STEEL %PVC J]OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS o HOSE <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: B Yes )(No (NOTE: MAXIMUM REE-FALL DEPTH IS 30') <br /> 0-4111 <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: V.DTHER.:� APPROX.BORING DEPTH n-' []BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> i ' 'I j' &t ,/� 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 Ord' ances, R d Regulations,and all applicable California State Laws.nn i, L i <br /> /\ wt �- Title/Company, 1/I.G'�1'��'C�PI61e(A <br /> Signed x —a I <br /> Print Name 1—I- + �f�l� +D l !r (t Dateruy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 15S� L---,- <br /> WORK PLAN DATED: tin 1 <br /> Date Issued vo ts"I O'er Area � L <br /> Application Accepted y Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date I <br /> COMMENTS/CONDITIONS: <br /> .ate 5 Cnc-ociv�' e..r o(i^ &g, l l e r cd <br /> � tZdA1. Lf tot.ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ZACA $°l• $ g, 9J 131 ' I la So n SR# DOS244� <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 />