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a -1• . San Joaquin County <br /> ofa Environmental Health Department SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 MITIGATION <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 descdbed. 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 /> Assessor �. <br /> WELL Location �J�g W. C, ar{-tt^ 1A1 4vl,.Cross SbeelVnrJ 6Jra*1 City S�'UG�tpbj.,2ip Parcel# h! n.3 01� <br /> PROPERTY1 C� pp 1 r�yf y /� ry C <br /> Owner C,P, T- �.LC..- Address Tt0fb 32,'1?._City.�JSM�¢4P.. !Zip ISZPhone# Ljo ZQ"1 3qt/ <br /> C-57Contractor to lb�c._� Address l�bl rna Lr LVL - clh_?ic�mdf0tZnggg2/.i z" honen.S10 Z366LSL <br /> Consultant/Sub Cnh l-.�F-A- AddressLj�tIUQY'St�t��. City , Lick Phone;M-za7q S0 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> `kNEW WELL/BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) E DESTRUCTION (choose type below) <br /> Q SOIL BORING# gOVER-BORE. DIAMETER <br /> 7F:VELL if_Y4\W^Z-0 rt�2-3 a PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS It <br /> �bLtONITORING -FOLLOW STEM DIA.OF BOREHOLE 9';110 MULTIPLE CASINGS E MULTI-LEVEL WELL CASING DIA: 2- <br /> p EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS 4 OL.Yy TYPE OF CASING: 0 STEEL U PVC Q OTHER <br /> I1 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL2 r k / TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING Q HAND AU ER GROUT .BORING <br /> IG DEPTH—t-11 <br /> EPT�17.@] \ 0 <br /> OTHER: may`,-,'f.,'THER � APPROX.BORING DEPTH d �0 1 -OLTED TRAFFIC BOX or STOVE PIPE <br /> ..`` ' 0 CONDUCTOR CASING PROPOSED K10 (if YES,list specificallons in comment section) <br /> COMMENTS: MW--2-3 -Q.\tet 1, t' -sntJ\C _o r Heft ft . <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 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. <br /> Signedx— ������ Title/CompanyWDC Exploration & Wells <br /> Print Name Chris Tatum Date 9/6/67 8 <br /> DEPARTMENT USE ONLY r I. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: qL{O Ct ou,7t L )cry <br /> WORK PLAN DATED: 12,12 zlog d- <br /> Application Accepted By o r-. Date Issued 9 /116 Area <br /> Grout inspection By Gl n,.,.o✓. Dateo�'2%e�Finai Inspection By ,y',�p_Date <br /> Destruction Inspection By Date' <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK RECD BY I DATE PERMIT l SERVICE REaurSTdf INVOICE <br /> 3Sol Locgz (,r.( q1II1e? SR# S18cq g <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6122,04 <br />