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4"'" SAN JOAQUIN COUNTY <br /> 'O p, .. co <br /> N a EN'rRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.sjgov.org/ehd UNIT IV <br /> `1"` RlN <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 Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> N J�• _Zip q5336 Assessor's <br /> Well Location i?�r r'` Cross Street � �� - City � �1tZ Parcel# zSCGfc�.Z3 <br /> Property (� ` 1 / <br /> Owner I t n i oA ?CI&�C_ ti 1-- --&dd ss �t'���7 �oor(? cj 4 ���� -City 01U4. N3 Zip C�1-7 Phone# C')-�S 3�--275� <br /> C-57 Contractor w���itz�r� �Jt1�li rte Address 7 5� (^ s ' cr City " �V,S�ta Zip 61`-15-7 Lic# -110679 Phoney <br /> Consultant/SubCntra E?:K Address WZ414 P, r:h?> UJrzc City (add RyOa' Lic#IC6c6( Phone bi6�-�5I-UI?q <br /> 1 <br /> GIS Coordinates:X 'y ,Township Range Section <br /> '"r RK TO BE P'cRFOR!'AED: <br /> EW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑ PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t� <br /> YMONITORINGOLLOW STEM DIA.OF BOREHOLE _ ❑t+,,\\MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> Vl <br /> El EXTRACTION /❑FAIR HAMMER/DRIVEN CASING THICKNESS SG� LL6 TYPE OF CASING:❑STEEL j/C [I OTHER <br /> r ^ <br /> El VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL _] TREMIE TYPE TO BE USEDrxX'/_AUGERS❑HOSE v J <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑SOIL BORING [IHAND AUGER GROUT SPECIFICATIONS .1 ^?1t st?n F <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH U` IILTED TRAFFIC BOX OR [I STOVE PIPE~ <br /> CONDUCTOR CASING PROPOSED 00 <br /> COMMENTS: (if YES,list specifications in comment section) <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all icable Calif rnia Laws. <br /> Signed �� Title/Company f ��}C )Efioj� c�c <br /> _1n.0 <br /> Print Name MtL5 (A 11(UGV <br /> Date ( 1��j <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY I/ DATE ISSUED �$ AREA )f57 <br /> GROUT INSPECTION BY 0 2 u��3oh FINAL INSPECTION BY�� �TutZc«��/3 DATE I8 D� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> Rein—.+ ►'eiS SUP i v W&od wv e-d be,1 1 7 � aecrJ �iv� 2S'l <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 35-o3/ z 9 �4 3 63 " 36179 , 71_,1-'7r- <br /> 3G259 C'N%Qi-fzyc SR#UaS�l37� <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 <br /> WELL PERMIT APP <br />