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San Joaquin County iJ P 1 <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 pax: (209)468-3433 Web'www.sjgov.org/ehd UNIT IV <br /> 3 Well Permit Application <br /> e—NOW-REFUNDABLE <br /> ///)���/��PERMIT EXPIRES 1 YEAR FROM DATE ISSUED z"� L_yJ <br /> Application Is hereby made to Sen Joaquin Goounty for a permit to construct andlor 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 Fnvironmental Health Department. <br /> a. i � 1_ it Ysessors p <br /> WELL Location �Z7D0 fI'TS Stress Street it <br /> C6. ^qty ';fa L'.'Io�. ZIP�'�?o Parcetk it(J� <br /> T— _. o <br /> PROPEr— <br /> owners ;� <br /> dress <br /> s./I/. >GP-.�Otada �l ,.$Y-.�s/ _ <br /> � _ tY .ip SSOL PhortetC,�9• <br /> C-57 Contractor !_a, L, Address,l3� %.- J�„-, City��U�:.��., 'Ztp 7U LIG# 47 Phone'R 11 hS-FII�. <br /> Corrouhant/Sub CnG Address t ' <br /> . CitgLIG#, PhoncY_, <br /> cX <br /> GIS Coordinates:X 3 Y-12-1. 2_5L Tcrvmshlp Range - _Section <br /> r F <br /> vl <br /> WORK TO BE PERFORMED' - z� <br /> D NEW WELL t BORING (CPT,GEOPR08E,HYDROF JNC .HAND AUG OTHER') D 6ESTRUCTION {choose type belowi <br /> 0 SOIL BORING# _ /A / ,g0�^ �,a� pE1?B37ZE—!3t ER <br /> D WELL# G+' �yR�F"✓' /1r_..e.L'r" RE$SUBE GROUT <br /> 0•Other © K (Yu""4 NS <br /> COMMENTS: /'71-- ois-iz t74-PL; l3 .174._ 9Js,-15. .. _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE__ 0 MULTIPLE CASINGS 0 MULTI-LEVFL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS_ TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> D AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') 6 <br /> D SOIL BORING 8 HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE I <br /> CONDUCTOR CASING PROPOSED (it YES,list speo(ricattons in comment Rection) 1 ' <br /> COMMENTS: i. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. I <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that i have prepared this appliestion 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>< <br /> Prim NamDate 00 oro - <br /> �y LO� 2>i <br /> WORKPLAN DATED: DEPARTMENT USE O1 - 3r.2.6 <br /> SITE MAP IN UNIT IV FILE,ADDRESS- ld 'IV. 2rYjZOt o <br /> Aggf <br /> Application Accepted By Date Issued Afea <br /> ©6 <br /> Gr&f Inspection By DateFinal Inspector,By t7ate t Q <br /> Destnrction inspection By Date .. —1 O <br /> COMMENTS I CONDMONS: <br /> ECODES <br /> G ONLY: AID# FAC# _ <br /> FEE INFO AMOUNT REMITTED�CHECK# REC'D BY DATE .PERMIT i SERVICE REQUEST# INVOICE <br /> OZ6Z l ' situ p(ot�1.19 <br /> C-57_ W =WAIVER_ C-57 Letter of Authorization to sign permit Encroachment ddc 73 O 6 <br /> 5 <br /> F.1111329-02-Ml WEB - J <br /> 9,11/2007 - ��S fQ Ll I t n <br /> �3�33 FILE COPY <br />