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.,,w San Joaquin County y <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 /> o Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 TiTitle,Chapter 9-1/11'5.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location�0 Q 1 4 G-[- CRfA Cross Street U Q��Y City Le ( 2ip rs � Farce wQ <br /> PROPS 7Y /� - CSI Bd/. Zi6j'SlYi Phone# a <br /> Owner -0 Address �. W• / 9`7e) `� `^� .nes �` �y <br /> C-57 Contrac or����+W ,r ,I Address7Q 3(17.17_ City l�^�l ZipqDQjLia V r 9 Phone# ; 7& - <br /> Corrsuhent/Sub Cntn-yil V G / 4 U 11� Address?0 BOX /5; City rl Lic PItona#�7f1 c <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> K <br /> ` NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) D DESTRUCTION (choose type below) <br /> /' U SOIL BORING# a OVER-BORE. DIAMETER <br /> )(WELL# 'I` p PRESSURE GROUT <br /> o*Other GROUT SPECIFICATIONS <br /> COMMENTS — <br /> TYPE OF WELL IN TALLATI N TYPE CONSTRUCT <br /> ION IC W <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE_F!11_ p'MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS 0TYPE OF CASING: a STEEL PVC p OTHER: <br /> a VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 7 TREMIE TYPE TO BE USED: IgAUGERS u HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p rya (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 171 6 W� -AhA <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH_IA s�OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> .[� CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Ol��S�IXA/t <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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x �� Title/Company ?/-I Ajo r �- <br /> Print Name yZ V Date T <br /> DEPARTMENT USE ONLY J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S P (-a^'� Cp� <br /> WORK PLAN DATED: 1 <br /> Application Accepted By LI�• A Date Issued �` Area g,L7 <br /> Grout Inspection By 4I - Date I /-13 Final Inspection By Date <br /> Destruction Inspection By Date PP <br /> COMMENTS/CONDITIONS: ✓ 'L '�'•- l dL` Ch ' •.L 100 -05-0 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR* <br /> C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment clot_ <br /> FHD29-02-001 WEB <br /> 9/11/2007 <br />