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P4U1N #n Joaquin County <br /> i\ Envi mental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> c• , ; <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 /> Assessors <br /> WELL Locationc,#/LOI/�/,!}L L}I�iE. !LR caD`oCross Street G IE)3Pc/L City JTO�k &% Zip S�/S Parcel; �—aj <br /> PROPERTY OwnneOT-6ck'AJ r ORTCA d/es01) s�u 6ak SISI city S7ac TK a✓ zip�5'Z0,9Phone4 ° V - °3'?,? <br /> C-57 Contractor H/U o��O,,nnWgQO D/�14� dress �O SOki 336 CityRIO VIJT ziptW Lic#_'/od"'Phone#-7d7-f 7Y-41301 <br /> Consultant/Sub CntrPADU— 4S-o(. //V(. Addressoo Ci�.w�Wc# Phone# <br /> GIS Coordinates:X ,Y Township 2N Range 7c Section 3a <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CP GEO OBE, HYDROPUNCH, HAND-AUGER,OTHER`) D DESTRUCTION (choose type below) <br /> SOIL BORING# DIM D OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING ?g�_HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS NS;'1I TYPE OF CASING: 0 STEEL D PVC 0 OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T / TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes *No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS__4V f{47 c 9XAC I')7 <br /> D OTHER:_0 OTHER APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IV 6 (if YES, list specifications in comment section) <br /> COMMENTS: S E 6- .R:j—IA,_gCV W 6i/Lk PL q u <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 Ordinance <br /> nn les a gulations, and all applicable California State Laws. <br /> Signed x Title/Company l�R°SQG'r 6;� .v61"r f�O R/c. � }g5co n <br /> Print Name �r�'�N C—OW11CWILL Date �1 Pglo7 <br /> DEPARTMENT USE /ONppLY�� <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �1 0 <br /> Application Accepted By Date Issued (d`1/0 ( Area / <br /> q 7 <br /> Grout Inspection By '� Date �D 07 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 5 �rSS <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 />