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San Joaquin County _ <br /> Environmental Health Department SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgoy.org/ehd MITIGATION <br /> Cg11F0R[I`T• 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 const=t and/or install the work descibed. This application is made in compliance with San <br /> Joaquin County DewtopmentlTitle,Chapter&1115.3 and the Standards of San Joaquin County Enmronnmenit�al Health Department <br /> WELL LocatlonlULi Ll —1 le.el I S� Cross Street�+1•IXYA/'}Q�'�City s'/ptft�tl bi Assess0 <br /> ---y1--P Parceilk, <br /> PROPERTY ( Q <br /> Owner-� rf�tf`�x(�dNAA00 Address �C}(�i y 1 "7V,, _City Cj4W1L'iPQ�)Pho7n�e#�� 0 aS1-890`� <br /> C-57Contractor Ll 0 ,`(' A Addfess(Q(1( m.Q+yam(' -y+R 1 City L (X�Lirlevw ph Z3ti 6�Z. <br /> Consultant/Sub Cnr C--(�,IV Address�R4yq.elygmt0.QIN'.CityuC* Phone 45S-4RS0 <br /> GIS Coordinales:Xe Y Township Range Section <br /> WORK TO BE PERFORM - <br /> YJEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) O DESTRUCTION (choose type below) <br /> L BORING AOVER-BORE DIAMETER <br /> ,VEWELL#_ YYI.v.j—21 <br /> O•pther 11 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> rONITORiNG D HOLLOW STEM DIA OF BOREHOLE9.,r Irl b MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: Z'r <br /> O EXTRACTION O AIR HAMMERIDRIVEN CASING THICKNESS Stip LA TYPE OF CASING: 0 STEEL VC <br /> R OTHER: <br /> p VAPOR O MUD ROTARY DEPTH OF GROUT SEAL �y r TREMIE TYPE TO BE USED: �UGERS O HOSE <br /> PAIR SPARGFJ OZONE 11PUSH POINT(GP orCP)GROUT SEAL PUMPED: OYes ONo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS �f f}`C JY � V 1( <br /> O OTHER_ OTHER d OSeJ APPROXI BORING DEPTH E p IPOLTED TRAFFIC BOX or O STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED 11 h (if YES,list specifications in comment section) <br /> - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify:that I have prepared this application and that the work will be done in accordance with San Joaquin �1e <br /> County Ordinances,Rules and Regulations,.and all applicable California State Laws. Q <br /> Signed �� � rfelCompany WDC .Exploration & Wells C.3 <br /> PrintNan, Chris Tatum e"at' 9/6/07 DEPARTMENT USE ONLY WI J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 4r-i.0 G'v.av-{' o. <br /> WORK PLANDATEM.... <br /> Application Ad pled BY 1 1 k -_ Date Issued `�1 t Area,I v } a <br /> Grout Inspection By_ ! Date Iib l2v Final Inspection By f A�.a,,...�.�, Date <br /> Destruction Inspection By Date r <br /> COMMENTS I CONDITIONS: - <br /> ACCOUNTING ONLY: AIRY <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#. :RECT BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 16°I,ot Lvq+(z W SR# Jf ic6Cl� <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29.02-001web <br /> 6127XM <br />