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*San Joaquin County <br /> • <br /> z: o? Environmental Health Department SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> C'A 2009 <br /> 0 Well Permit Application <br /> -� 5 <br /> nn � o .M2N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApplicatENVIR 6Wquip County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Co"p hapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> _ ^ Assessors <br /> WELL Location alb S ,t�d lc� e l�a,e Cross Street Lod Aub. City LUPI- Zip ( 5 40 Parcel# J43` 14' 04 <br /> PROPERTY'UO-fcl- + I <br /> Owner 10'i4 P �L ck Address SU ` S'C�Q rd 1wL.tn. City Lo A Zip�s140 Phone# �� 3��"X73-7 ++ <br /> C-57 Contractor WJJJ 1AkV`K '6 r �q Address li Uu / 2�wt� Cityj 0 V,S Zipjy Lic#)]Co?y <br /> J I� �5e <br /> Consultant/Sub Cntr&IfAkS Lh v)"U,.i!j I �t -( <br /> _ Address 333c (�Mq!v�l"1C,Q:. City A 1C Lic# Phone# -IU(14- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) )(DESTRUCTION (choose type below) <br /> []SOIL BORING# OVER-BORE. DIAMETER IU" of it's <br /> []WELL# 'PRESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS V40LI SPU tlr`� <br /> Comm�NTS:U•" l�I`t W<<i5 J�tw MW Z MW3 MVS t:xcu�u�E VpA VP 1,03, �)S�rC (�•v,�"�tl'y _" <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:-_____ <br /> []EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> []AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or []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 <br /> Ordin es, Rules and Regulations, and all applicable California State Laws. I / <br /> Signed>{� L�%? ` Title/Company P rt;i ( t G?JIo9Si,'c � VUh Vy4h <br /> Print Name '� c� ', �L'Q4 -Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S <br /> WORK PLAN DATED: JF�o'ZI d <br /> CJ <br /> Application Accepted By Date Issued / Are % ? <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date ! c�a� r L <br /> COMMENTS/CONDITIONS: r W v(�J 1 (I e S t rlrf-rca..;J 16 t l <br /> ACCOUNTING ONLY: AID# co h &rrt t P.� <br /> FAC# CIX <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ;Ii o� o d a- KOM] S R# g <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />