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�PQUIN�� •San Joaquin County <br /> �O_ +Fw7 a •'0- <br /> �2 Environmental Health Department SITE <br /> N _ 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> • �� ) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> '0 5 2009 Well Permit Application <br /> ^'1/' O�j AE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicat'i{JV�tV VI quin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 G Assessors <br /> WELL Location yyL t' ;WA(ytu[ S� Cross Streets.- {ty ke(L.. City -Zip ISl`(u Parcel# <br /> PROPERTOSD�,Owner bAddress (5' .5tre T City Zip S <br /> hone# <br /> C-57 ContractorWwAf✓✓k �r•II�� Address SSJ Rlti fL04� City -)10071 Vy�ti Zip�ysll Lic#7IUiJ� Phone# <br /> Consultant/Sub Cntr5�r'A� S wy. Address�330 ��*`n�`I� Os•4Sso City Phone# J <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) ,t DESTRUCTION (choose type below) <br /> []SOIL BORING# ,(OVER-BORE. DIAMETER �I t <br /> []WELL# 0 PRESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS: MW --- <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 /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 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 D 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/Ordi ;es, Rules and Regulations, and all applicable California State/Laws. <br /> �/ <br /> Signed�f/" Title/Company <br /> Print Name AAt JJ 1'yk4 Date `t�0��U5 <br /> ® ` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: cjk � <br /> WORK PLAN DATED: S' ( O Q <br /> Application Accepted By Date Issued Are <br /> Grout Inspection By Date 0'7-0 D Final Inspection By Date d <br /> Destruction Inspection By Date D Q <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 /> a o2- ( o c�o (a-G h 161�j�y SR# s� 96 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />