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San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 / r / MITIGATION <br /> i (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ Il I UNIT IV <br /> Well Permit Application <br /> , <br /> I 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 ' hii;�eppllEhpn ,is. Ta e ip, compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environment4l%H€A�th 4ppartrtmdnt � '- ' ti <br /> L %'U Asrsessors <br /> WELL Location 2offS E. FiC(•MONT S7Ved'rCross StreelLAu ,GEL cityS?OCkTon/ Zip o5 Parcel# 141 - IIZ -03 <br /> PROPERTY <br /> Owner EkNEST FiJFP/ ANO Address,}1262rc A (Q r^CXWCitySG16r^_Zip i2e Phone# 9, /g � 9'083 <br /> C-57 Contractor 99 :17b411, L / �l7 Address 220 A/ . 6 RS ? S?. CitylJooD oAw Zip Uc# 02?3S/Phone# <br /> Consultant / Sub Cntr /TTG ASd'0C/47GS Address / 117 Lo A/E PALM AVC-City <br /> _MV1>&9-7!6 Lic# 9�_7 Phone# S79 Z 2 "z / <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> n NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') p DESTRUCTION (choose type below) <br /> O BORING * % 7- OOVER-BORE. DIAMETER <br /> ELL # X:V&J.Q f NIC WELLS aPRESSURE GROUT <br /> O 'Other GROUT SPECIFICATIONS <br /> COMMENTS: SEC A­-rci P/ LDr TEr T/I✓r, WD ,eK PSA Al A �F� sI8�a 9' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1r <br /> n MONITORING OLLOW STEM DIA. OF BOREHOLE /O=iZ"0 MULTIPLE CASINGS U MULTI-LEVEL- `WELL CASING DIA: _y <br /> 0� '�EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 9CY TYPE OF CASING: n STEEL B 'VC a OTHER: <br /> g'VAPXT�OR n MUD ROTARY DEPTH OF GROUT SEAL Sof TREMIE TYPE TO BE USED: n AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE g PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 305) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER:_0 OTHER APPROX. BORING DEPTH IJO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IVO (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 Ordinances Rules and Ike lations , and all applicable California State Laws. <br /> Signed d Title/Company /�iCo �E55/o�/�l- lL-oL Rj/1 '` �%L gsS't�rAIES <br /> Print Name oaf HA it�C� <br /> DEPARTMENT USEDate <br /> IONLY F � � ROPY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 201r5_ �.a rn+o ..71 S I oL/c �p � <br /> WORK PLAN DATED : S � $ I015 <br /> Application Accepted By Date Issued $ ' S D Area <br /> Grout Inspection By nenrc Date Final Inspection By (. K / Date 26 <br /> Destruction Inspection By Date Z pr-I-i J .,.. , t ,A- -4�I If I,J O .fd7 � 'lo � <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3 ro �q 1916 kti ejr`og SR# i Soy <br /> C-57_ WC - WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11 /2007 <br />