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San Joaquin County <br /> Environmental Health Department SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> t... <br /> \ � (209)468-3449 Fax: (209)468-3433 Web: www,sigov.org/ehd MINI-( IV <br /> 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 Devel m Till ,Chapter 9-1115.3 an the StandarOs of San Joaq in County Environmental Health Department. <br /> c 1K� Assessors as-5--100-10 <br /> WELL Location 7i if ross Street City 7f Zip Parcel# 0 S$ <br /> PROPER-Q( V) LL // / a 4 -(90-Dja <br /> Owner 11�G ��i-��00-Clk 'y7?1r flet ///��4dC City I�f�P� Zip I16'?Phone# `V 056/;Pa- LD <br /> C' fic F-r <br /> C-57 Contractor .J�'c'CT171�u Address � � It cW4wL City na Zip`1 SLic#r/0,7G8 Phone# 416 r- 7tr A <br /> Consultant/Sub Cntrf / 1J[! Address v � e City +r+v Lic# Phono# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE, DIAMETER <br /> WELL* 0 P-7 h PRESSURE GROUT <br /> `OtherP rl_ 1 `i GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: r' _ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Zkk Y$ TYPE OF CASING: 0 STEEL XVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL AP TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:It Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: Pete°,, 0 OTHER APPROX.BORING DEPTH S 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /U (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 Ordinan es, Rules and Regulat- ns,and all applicable California State Law <br /> Signed x (/ � � _.. Title/Company �ed CJ�QI f5� /t lei^�J /e pi <br /> Print Name �`aIUCI$ X deaw �� 17 v <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 10 112-010 2 <br /> Application Accepted By . Date Issued C) d ,rl Area �� L <br /> Grout Inspection By Datec Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOiCE <br /> C 14110 b7 S R# �a2 <br /> C-57— WC--WAIVER C-57 Letter of Authorization to sign permit—Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22104 <br />