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VAN", - L� <br /> o San Joaquin County SEP <br /> �� Environmental Health Depart, eat Q X007 SITE <br /> 0 { 600 E. Main Street, Stockton,CA 95202- OIIJJ�gE MITIGATION <br /> N'f�E��r <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgRV/SES �{ UNIT IV <br /> �rFO-. �� 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,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> T� Assessors 2� i yU 12 <br /> WELL Location -7(p-75 l.� (�E�1 'St Cross Street 06:1%ry%.&K rcct City Zip Parcel# <br /> PROPERTY 1 <br /> Owner '-eVono-Q- rn 1,C-✓ Address PO BoK 33(O City l(0. Zip C►4 Phone# 209 b3S3�f(or- <br /> C-57 Contractor R5( Address_Z-20 N.Cast St City zipC'k Lic# Phone# 530-SGB-2-424 <br /> Consultant/Sub Cntr ASSoG. Address IW7 L..owe-Pa\w► City YMoaj,s-r0Lic# Phone#Zqq 57`/-Z—( <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# C �5e-c&sro�Dn vaso,- Q OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> 0*Other JJ Z <br /> GROUT SPECIFICATIONS <br /> COMMENTS:�Oc 1D�d„1�1 -Do,*-eA �u 00-7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t I <br /> U MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:�( <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC Q OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL l�t TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE ;PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH ISI a BOLTED TRAFFIC BOX or a 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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company -B ran ('Aar- - (L 5506 <br /> Print Name Date (o 10 7 <br /> DEPARTMENT USEONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7,1, 75 W <br /> WORK PLAN DATED: 09, �45--kt( 200`7 <br /> Application Accepted By ./t/e// Date Issued /cc�� -�/1 /Q / Area 1#5- <br /> Grout Inspection By Date 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/SERVICE REQUEST# INVOICE <br /> 3s�3 �( n' 3&3 `� r5 CNT<2 jl,o CjJ SR# 0051899 <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 />