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0 0 <br /> E3)I�l yr <br /> o�ct�t?y. o <br /> San Joaquin County .fl,�='il �!C� I <br /> Environmental Health Department SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 Si_ t MITIGATION <br /> :www.sjgovtorg/ehde <br /> - <br /> •cq <br /> (209)468-3449 Fax:(209)4633433 Wb� �a,, � 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 /> WELL Location . . to vtziAssessors <br /> Parcel#lbfm OD <br /> PROPE t/� <br /> Owner ��(�.A.V( _ dress <br /> 6[ City Ir Zi Phhone# �1 <br /> C-57 Contractor IRM r— Address lQ6\ D2KDA twa.. 1 City p yf�I4Licag'33 phone# I Z bZD L <br /> Consultant/Sub Cntr {� � - Address\ 4 : r(Ilf I Ciry�p, [�tlr anene#707935.483-0 <br /> GIS Coordinates:X Y _ .Township Range Section <br /> WORK TO Be PERFORMED: <br /> EW WELL/'BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# O OVER-BORE. DIAMETER <br /> A%VELL# rnU l —2'7 O PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r r (J <br /> -AONITORING aHOLLOWSTEM DIA.OFSOREHOL MULTIPLECASINGS <br /> O MULTI-LEVEL WELL CASING DIA:ZSjJ�Y <br /> O EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS -C N D TYPE OF CASING`. O STEEL O PVC B OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 6 1-1 TREMIE TYPE TO BE USED: ;OUGERS O HOSE <br /> p AIR SPARGE)OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE,MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING O HAND AUGFR GROUT SPECIFICATIONS '964-s]" '71 1 ) <br /> p OTHER THER�. APPROX.BORING DEPTH BOLTED TRAFFIC BOX or O 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. 1m <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin d. <br /> County Ordinances,Rules and Regulations,and all.applicable California State Laws. 0 <br /> Signedx -- 7— TRielCompany WDC Exploration & Wells C' <br /> Print Name Chris Tatum eao 9{6/07 # <br /> DEPARTMENT USE ONLY <br /> e <br /> SITE MAP IN UNIT IV FILE,ADDRESS:. q 'G �- <br /> WORK PLAN DATED: �zz/0 6 d- AcUgl rJn--;Z <br /> Application Accepted By S�w_csn.-. Date Issued/ 11/0 3 Area <br /> Grout Inspection ByDate1 0�2 Final inspection By r ,tl. Date rpf _ .,a <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID#: FAC#: <br /> PE CODES FEEINFO . .AMOUNTREMITTED CHECK# RECD BY DATE : PERMIT I SERVICE REQUEST# INVOICE <br /> .3 5-0 Zoo j2 Gk q I, 'SR# Sigq <br /> C-57 WC_-WAIVER, C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02.Oolweb <br /> 622104 <br />