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San Joaquin County <br /> " SITE <br /> Environmental Health Department R <br /> 600 East Main Street, Stockton, CA 95202-3029 - MITIGATION <br /> +� %1 (209) 46S-3449 Fax: (209)468-3433 Web: www.sjgov.orWcha jJNIT IV <br /> - <br /> 4, 0 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, µ611L <br /> (� }},� t Assessors hart C. ( S't'rlfE� <br /> WELL Location ��lit�lh "\ C'\' � Cross Street °—IoSan City C Zip � Parcelit <br /> -PROPERTY <br /> C [T lra-tt.v.i' ' <br /> Owner c .+,�?+ :_c-�u.:.eit�tie'_Address+qG -Ly4.,I VN CVy� '� DZ- City i�>i-i-F'-r�: ZipriS5c- Phone# SCC, 41titer+-1 Lt(� <br /> C-57 Contractor �I%iw�Address »- CtUGr, r,,� CitZip Lic#'Tlt"T Fhoned 7-c'' <br /> Consultant/Sub Cntr-YyA.'kL- � (9.C-Address%-'ZL"lk-r•=rd City ga.p.L Lic# 11tD1q Phone# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> .;.!NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER") D DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 'WELL# _ I PRESSURE GROUT _ <br /> ---- U-Other "- "— --- - - - GItUU1 SPECIFICATIONS <br /> COMMENTS: pro f I atl 3 We11S cUe 'orw�l OwMaA <br /> 7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING c.q�HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_2"_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS&-\tL" 1 ?-:0-TYPE OF CASING: 0 STEEL "VC [I OTHER: <br /> [I VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> L]AIR SPARSE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER: 0 OTHER APPROX.BORING DEPTH to 4 °BOLTED TRAFFIC BOX or 0 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 /> I hereby certify that I have prepared this application and that thework 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��6 i /s�j`i-C-•'¢ S iN'�o \CJC n <br /> Print Name odytJ Date r�2-1 Zq,F ? <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: JS (q 0 p �7✓�.Ql✓t- <br /> WORK PLAN DATED: I I�, <br /> Application Accepted By Date Issued Area T` <br /> Grout Inspection By �m,� Date .Z- (] Final Inspection By t�'4'Lr7 ,,/ <br /> Date ZI .1 B <br /> te <br /> Destruction Inspection By Da <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 /> 174 35 DA ;Ak4 3 3 1'a�,►� �( 2I b sR#53g$ <br /> C-57 WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> £HD 29-02-001 WEB <br /> 9/11/2007 <br />