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San Joaquin County `J <br /> Z Environmental Health Department _. SITE <br /> ^I <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ' (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd C UNIT IV <br /> cR 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 /> 2 O d 7 <br /> �" Assessors /p/ <br /> WELL Location 1�IJ���: �� ��'� Cross Street City }`C¢�i�1'+f Zip���X' Parcel# l/ / <br /> r•�7A\w�N++-R- b'i :"a- '1w•rvsl�cnn -.z „P 'r53;:� •„ri''--`S `-t`C': <br /> PROPER­ <br /> Owner -Address.- <br /> _Address: _City_ _Zip _Phone#_ <br /> C-57 Contraclor\?J=fri'�44) ��,U'�Address'�= W-ii,—45� city '�wa Zip Lic#-rlC'C'�TPhone# �2:`�-S ter •�`?”" <br /> Sr i,-euT`-rf �.x•�- <br /> Consultant/Sub Cntr'_�TL.i%�i�:> t'i�v%•-, l`.•�-Addressr'��:`+�• �-s::ikc..�- City Sa F-t= Lic* Phone" <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> .:. NEW WELL /BORING (CPT, GEOPROBE,HYDROPUNCH,HAND-HUGER, OTHER*) [] DESTRUCTION (choose type below) <br /> 0 SOIL SORI1'^" B OVER-BORE. DIAMETER, <br /> I-E:INELL# t' �:!-•i 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE tv . []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SaK40 -V�-r`-TYPE OF CASING: 0 STEEL Y_PVC 0 OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ;L TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> IJ AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> H SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> [] <br /> OTHER:_0 OTHER APPROX.BORING DEPTH \0} `''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 the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed C %'r"' f"-"�� Title/CompanyGc'cm i <br /> Print Name011v[1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S <br /> WORK PLAN DATED: I I (3 U 'f[ �1 <br /> Application Accepted By tit? Date Issued L4 IV U Ar1e1a r <br /> Grout Inspection By`�`)� 1 <br /> Date q 2-ZO Final Inspection By - Date Yt 2S-161 <br /> Destruction Inspection By J Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> -b5-0 <br /> 2,!5D?) ;A`4 �(� " � l l)� SR# -5-30193 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> END 29-02-001 WEB <br /> 9/11/2007 <br />