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y San Joaquin County •- 1 LE COPY <br /> Environmental Health i i �I <br /> SITE <br /> y` < 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 40(209)468-3449 Fax: (209)468-3433 Web: wwwsjgov org/ehd ' /�G UNIT IV <br /> 4/%FORN�P Well Permit Application CIS\ '&•' r,t,v.. HE4tTH <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.Assessors.Y6 i,_ <br /> WELL Location !W 13 Old sDamsl. Dr. Cross Street UQ Dr. CiryS VCb on Zip 9SZ0 6 Parr,eI#__,[�___ 1— <br /> PROPERTY 'C ip& ZPhone# �T o J / <br /> Owner <br /> OPER <br /> Address UJ <br /> p <br /> C-57 Contractor i `0 Ian Address 23 WraWam Dr City '�' KS or, on Zip 05 Lic#6 7 Phone#L01 11'65- 717. <br /> Consultant/Sub Cnlr�124M(��rIX �enS 1.11 g Addressf�f F ARI eat A&1''101 City e o Lic# 60111'S'0 Phone#sS�164 -1S3S <br /> 1 tiv nd fifndl'Range Section <br /> GIS Coordinales:X 632 6152 •53 ,Y Z1�7z33 z•56 ,Township �% <br /> �j--4— —IZ 1.31 <br /> WORK TO BE PERFORMED: <br /> )KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) GDESTOVER RUCTION <br /> RE. DIAMETER(choose type below) <br /> 1]SOIL BORING# a PRESSURE GROUT <br /> 'WELL# MVJ-20 GROUT SPECIFICATIONS <br /> 0`Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING *HOLLOW STEM DIA.OF BOREHOLE H'" 0 MULTIPLE CASINGS E MULTI-LEVEL WELL CASING DIA:_ _ <br /> U EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS 0.of-2 TYPE OF CASING: 0 STEEL PVC U OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL ( ff TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes !No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> U SOIL BORING 17 HAND AUGER GROUT SPECIFICATIONS Neat 42e jp, w;d 3% be tonioy- <br /> OTHER APPROX.BORING DEPTH 30 f-{- BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Q OTHER: D <br /> CONDUCTOR CASING PROPOSED No if YES,list specifications in comment section) <br /> ( <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 havprepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi a es RUIee ulations, and all applicable California State Laws. <br /> Title/Company I <br /> bccGr n Q�r <br /> Signed x <br /> Date <br /> Print Name <br /> DEPPARTMEN'T/ USE ONLY Z9 bQ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 20 �/ C <br /> WORK PLAN DATED: <br /> g 1� / <br /> Date Issued =m Area 66 <br /> Application Accepted By Date $r <br /> Grout Inspection By Dat ' !7 Final Inspection By _ <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> '740Mui /3� 99 rD. op sR# pS �v 15� <br /> C-5 — WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc-�k7l?eg <br /> EHD 29-02-001 WEBS( Q�•0 <br /> 9/1112007 <br />