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0 <br /> X004 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 /> <rr•oRH�P 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, <br /> '�Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 53 +1��1P)'C� lgge, Cross Street �._ .,Assessor <br /> s {t1� (� �//yy�� �) City(;fZL''I nn Zig YV Parcell <br /> TY <br /> OwnOerEC1 l �[±�O0S(,I'rtrJl 01' ddress_1,��/t}17E Vv <br /> ,7'fn' ^ City Z_Zll L�Fhone# 371 h-t� G�'� <br /> C-57 Contractor l Address -OJ 1SW.w X-�t. Q City�3 -F Zips / Licll(, Whone�rk�}�7/-G[,�00) <br /> Consultant f Sub Cntr 11 ✓1 Address tSJ7 S N I-rX. City /1 Phone �) )t / (it/ <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> %AcNEW WELL/BORING (CPS,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> OOILBORING# ?mayn ,A,r<`M I;` 6c DOVER-BORE. DIAMETER <br /> WELL# 6- PRESSURE GROUT <br /> 0.Other GROUT--SffPECIFICATIONS <br /> COMMENTS: -� Sa,� riV1.cS �� t� L)— v""(bT/Un _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOL . ��ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING Dll- <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ',rP, S' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 14IR SPARGE/OZONE RUSH POINT(GP r CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: rAAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING OHAND AUGER GROUT SPECIFICATIONS Qulh n(zLy7r�t no�. V'mf•�i�PM C <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH v 0 BOLTED TRAFFIC BOX or g 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 Ordinance Rules and Regulations, and all applicable California State Laws. y <br /> Signed z Title/Company �ry 550'V7 <br /> Print Name aY) I .M-ay� Date 0'- 'dO©•q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: & 5, CAtI� 6"-e y &j.tkj,-usr S,.te <br /> WORK PLAN DATED: -71911 8 1 A&-& <br /> Application Accepted By Date Issued /%I Areas9? <br /> Grout Inspection By Date �� al Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: llilr✓ Zt "16 S• -Q/1�Cfr <br /> ACCOUNTING ONLY: AID# Ill FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �9b S s F - �t8b jo z,� n sR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-o2-001 WEB <br /> 9/11/2007 <br />