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o �fH Wan Joaquin County • <br /> r� o� Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> L 'l �489)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> P rt ^Ijn8 Well Permit Application <br /> �� <br /> -BION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicafron ereby made to Sari,loaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin C u y Development Title:Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> `, Assessors ,/r... �.p <br /> WELL Location . 3? oQ c� Btrq -L� cross Street,7' o Q.w city i Zip is 30 �iParcel# - U -1 'dl S <br /> OwOerEIlYwt}t, nnCDN,61t(iYsn Co. Address -5�r•Sk/M �3' I* &X/SICity_J�k fDfr�_Zip RS��I Phone# Z�l'q�Z'yJS(� <br /> C-57 Contractor W 11(4/111174_Address 115-0 (1'fte P .City M#(h'.k-bZp c1SS3 Lic#4flSlIS Phone# 9ZP-313-J-YOD <br /> Consultant I Sub Cntr 2011arfor-4 tr Si Address 400 &ffis Sfi -far•Fe A _City_E.2 lc Lic# Phone# 5117- q7-0-3371 <br /> S37I <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERF <br /> PEW WELL GRIN CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> POILBORIN # Z3 &rjljo( DOVER-BORE. DIAMETER <br /> 0 WELL# D PRESSURE GROUT <br /> R'Other_ GROUT SPECIFICATIONS <br /> CeNM <br /> TS: de�Cn tit 4/1`4(1 c rkPlaN <br /> 'MEnof /.r yr, OIc1<R• er ui rn:l /v 'a n_r vi <br /> :PF rr- Motperwff4 ve- w.'ll baCkic,'I'bcN r rte' Pow 41 growfi, <br /> ELL <br /> TYPE OF WINSTALLATION TYPE CONSTRUCTION ECIFICATIONS <br /> D MONITORING WHOLLOW STEM DIA,OF BOREHOLE Z tj D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC D OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> j3LSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �I oLlRn.�/�C' <br /> 0 OTHER:________ _D OTHER-___ —__ APPROX BORING DEPTH Y, S IO I� if C60 BOL D TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED I-10 a (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 Laws. /_ l d � <br /> Signed x A Title/Company Y��'-� /wN )e rmaa- �'�or�sr r CL Ay wt J <br /> Print Name l.C{CM PM �f t Date Z/ z9 0� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �✓ -I1b <br /> WORK PLAN DATED: a e23- 'D <br /> Application Accepted By _ Date Issued 3�`t��'8o Area 59 7 <br /> Grout Inspection By�Date 3 6-Y Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: 0 G n n I <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 1o3� b 3�� B SR# S3S� 1,f <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 />