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San Joaquin County <br /> Environmental Health Department SITE <br /> < 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> L 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 31115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> o <br /> /� L0-fe Assessorsf,s/w_� <br /> WELL Location .J oZ/ A l k e�a"e Cross Street M V city 4-0b ! Zip gSZyb Parcel# r q <br /> PROPE y <br /> Owner .1lTQrte- ox Address,-20;L3 E. wa�(�fnnl City Zi ?Phone# t� <br /> C-57 Contractor I T�IAA Address PD �?CY)C 7 7n City CtdA,f,,,,�(Zip�S'1yr Li '��� rPhone# 7'�r9 00 <br /> Consultant/Sub Cn <br /> tr�U& U 1 Address?O BOX !S"z Cty_ J 'V C! � Phone# 0 ' 7 Z/ <br /> GIS CoordinatesX ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 1]DESTRUCTION (choose type below) <br /> U SOIL BORING# 0 OVER-BORE. DIAMETER <br /> Q WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )KMONITORING HOLLOW STEM DIA.OF BOREHOLE 4j, 0 MULTIPLE CASINGS 0 MULTI-LEVEL <br /> , WELL CASING DIA: <br /> L g <br /> p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 0 TYPE OF CASING: 1]STEEL PVC 13 OTHER: <br /> )�IAPOR O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> `OAIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAvIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING O HAND AUGER GROUT SPECIFICATIONS Ae-ot& r Y �l/�IinA <br /> p OTHER:_ OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or 0 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. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nces, 5ules and Regulations,and all applicable California State Laws. <br /> Signed x_ , —1 1 Title/Comparry R/ ! e.. <br /> Print Name L,CAI C, s 1K. Date t a O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -!Nd Lff� t/ bP: %L3F8� <br /> WORK PLAN DATED: <br /> f' pa <br /> Application Accepted 13Y Date Issued Y� b� Area (� <br /> Grout Inspection B� Date / Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: b /✓ Sa <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3S01 8�- F; - i4*- y c- SR# <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 WEB //11 { t� <br /> 9/11/2007 00 <br /> 3563 Ry - �r�% S/� &011 Sia' <br />