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k�anJoaquin County <br /> Environmental Health DepartmerR <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/dDa(, `� 2g07 UNIT 11/ <br /> 6 `'�P Well Permit Application �! kjL� HF,0H -- <br /> pp �f��4�Ui�ik,c1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE&EPI 'i f SE \"GG—S <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 /> WELL Location j Z� Z NS�t �"�'Farq''q . Cross StreetAI , Q City S ,c Icb� Zip S _0� Parcel#Assessors I Z5 luU I <br /> C4iher�►te R [3eva>�e)aT� 31 <br /> PROPERTtIe don P1 rt G �o�+ 4 -a19 <br /> Y <br /> Owner �— Address City Zipa Phone# <br /> C-57 Contractor R T Address ZZo ,N, L�,S St City lJdUP011 Zipl"7t Lic# 90134 Phone# <br /> t x r, <br /> Consultant l Sub Cntr 5 CK wtiv d Iw S �k kIAddress 13)C_(a mtr*& !' <br /> tn1 k_k D,,City PW rk LIt# Phone#fad`06 ' 6004 <br /> GES Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> VEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> Q SOIL BORING# 0 OVER-BORE. DIAMETER <br /> JKWELL#_V P-I! U X,V(1-3 _ Q PRESSURE GROUT <br /> Q"Other GROUT SPECIFICATIONS <br /> OPY <br /> COMMENTS: <br /> TYPE OF WELL, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 16 Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:W r_ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS_t 4� (A TYPE OF CASING: Q STEEL Q PVC OTHER: k F(P� <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I r�o� TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE!OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes no (NOTE: MAXIMUM FREE-FALL DEPTH IS 34') <br /> Q SOIL BORINGr �iAND AUGER GROUT SPECIFICATIONS f ��AAA <br /> �GTHER: 6LUSL.1Q OTHER APPROX.BORING DEPTH 61 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> O ll -- LCDUCIT�OR C j SING PROPOSED U (if YES list specifications in comment section) <br /> COMMENTS: SOi I Ud :^ rUb�S ��S1 W1. �P1lurt 4,�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 Or rna c s, Rules and Regulations, and all applicable California State Laws. <br /> Signed x � __ _ Title/Company Ge0(� S 5 l� ty) Lj, <br /> Print Name bVjj,^q Date ')//O) <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 Z r S+ +' <br /> WORK PLAN DATED: S e r 14, .26127 and „ + 9 9007 <br /> Application Accepted By YJ Gee r►Q. G C,LI f^f n e Date Issued — 1 0 Area 14 S <br /> Grout Inspection By V i& r:as L,_Ynr tar t, Date o`t D 8 Final Inspection By ` ' at } -2 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: r + r- b -2 and V 3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3501 84.00 84,60 14325 LaM 11.2 •31-0'7 SR# 005' 30 34 <br /> C-57 WC"WATVER— C-57 Letter of Authorization'to sign permit Encroachment doc� <br /> EHD 29-02-001 web <br /> 6112104 <br />