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• �U <br /> San .loaquin County BILE COPY <br /> Z6600 <br /> vironmental Health Department SITE <br /> East Main Strect, Stockton, CA 95202-3029 MITIGATION <br /> i# rZ' <br /> 209)468-3449 Fax:(209)468-3433 Web: «1vw.>_jgov.org/ehd <br /> ' UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDAPPlici <br /> Joaquin <br /> is hereby made to San Joaquin County for a permit to construct andfor install the work described. This application is made in compliance wit th San <br /> Joaquin County De�Jv/el�opment Tttre.Chapter i}117 .3 and thN'landards of San Joaquin County Environmental Health Department, <br /> WELL Location� Assessors <br /> D _Cass Street Yl4e{!� City Stn��/o, zip_35"zoa Parcell if7-n2o_r<: <br /> PROPERTY <br /> Owner all`,lo t {��./, <br /> - _._.. Address ;oS <br /> -' --� y [ CityGio! ! (' ./,7.ip_.Y�Phone# (Q:S,19/% <br /> C-67 Contractorfr r .,., Sc..w/--nr Atldress 1 6 _ <br /> -�--- _�� �:,—citySf� cf----7ipfsl�ruas z sePhnnete (so9lrcf srirz 1 t <br /> Consultant l Sub Calf l,,,v/re _ Address S.] [ t..,.N/ c i) c,i O' <br /> 31-%() 1O� ry r[� /u #.Iz Ja PnonexLx C _fi7L <br /> GIS Coordinates X __,_,Y -(�• � �,Tovrn9hiuRange _Section c <br /> WORK TO 0E PERFORMED' <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') STRUCTION (choose type below) <br /> C SOIL BORING# - ER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> _ �....- <br /> �'Othor v 5 GRfUT SPECiFICATIO�NS _�,}j0- <br /> COMMENTS U- [ 3 [ -/i+%-9 !.,-/Jt S-(6�I$'/�S-t p bt--/ As-r,Suc <br /> .& P1./.-'+�/h 1 / Ssk.'tiVJ�t.r ,sti zshoa c' /�(,P/tonuis�/7<y,�s-2,s�E1 <br /> TYPE9F WELL INSTALLATION TYPE COClSTRUCTIONgP$ ECIFLCgTIONS NR �FS <br /> O MONITORING O.HOLLOW STEM DIA,OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 8 EXTRACTION 0 AIR HAMMERORIVEN CASING THICKNESS_- .TYPE OF CASING: B STEEL. p PVC p OTHER N <br /> 8 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED'. 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE O PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE'MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> U OTHER: It OTHER APPROX.BORING DEPTH O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _(d YES,list speclitcaffons 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 1 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 /> t __. TXIe/Company 5- /{' S .:/-c f - T.{e ro,...r._ G-r.,n fn<. <br /> Signed>t�nn _ - , <br /> Print NameL��lo^' �r�"' Date Ov2oll <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: //0 N. el— 6 <br /> WORK PLAN DATED: —4:7Z-5—/U <br /> v6d <br /> Application Accepted By _ — <br /> Date Issued 16 42 Area <br /> Grout Inspection By__ _Date Final Ion ByT 1 <br /> Destruction Inspection B Date '7IO <br /> COMMENTS i CONDITIONS: <br /> ACCOUNTING ONLY: AIDC FAC# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECKS REC'D BY DATE PERMiTf SERVICE REQUEST# INVOICE <br /> D. D7-& <br /> - � SR D(oo/9� <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment dor <br /> EHn29-02-0e1 WEB <br /> 911112007 <br /> FILE COPY <br />