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San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 DEC 1 $ MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.o�a/ehd 200= <br /> �wIRONMENT UNIT IV <br /> Well Permit Application PERMITISERVICES <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. O <br /> WELL Location r b S^"fl^ L:+�tdf�✓ Cross Street �' `✓CS`pity S`%o CKr�Zip ejSze Z Assessors/37 -36C>-10 <br /> PROPERTY r o <br /> Owner Re e^Tylvs6« LL< Address � 7o V�' PerT',7 ACIy S'AC Zip ?s�z hone# <br /> C-57 Contractor yAddress� (/^4 / ��` ` y�� <br /> CtlY � ic#--jjj90Phone# <br /> Consultant/Sub Cntr a IIF4— Kul,If <br /> dress So �,.e►�r7..•.f A3 erJ- fAc <br /> city Lic# Phone# 4/G 2 /M.l'/ <br /> GIS Coordinates:X ,Y ,Township /AJ Range 4F-9 Section t7 <br /> WORK TO BE PERFORMED, <br /> D SOILB <br /> XNEWWELLORING# FS OBBORING1CPT, EOPRDROPUNCH,HAND-AUGER,OTHER*) pDESTRUCTION (choose type below) <br /> \ <br /> a WELL# DOVER-BORE. DIAMETER <br /> a-Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLE .2 r'r' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC D OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE VUSH POINT(GP rCPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING OHANDAUGER GROUT SPECIFICATIONS_ Necr 1.114tA%—T r&1 ,7 <br /> D OTHER: D OTHER APPROX.BORING DEPTH _25— D BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—(if YES,list specifications sec <br /> in comment section) <br /> ) <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 x ?,-- Title/Company Sr L NV- J;OC t:o(,'T i/�a//a4 — k�w 1 <br /> Print Name Mx+ - A'A A. T,-7L, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /� 7 <br /> Application Accepted By Date Issued C <br /> Grout Inspection By Date T <br /> Destruction Inspection By ate Final Inspection By pate <br /> ��E Z Area <br /> COMMENTS/CONDITIONS: / "5 <br /> ME <br /> AID# FAC# a r4SS r 6 i �^'1 <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> gQ.Q7 �ec2�1 SR# �� kA <br /> C-57_ WC--WAIVER— C-57 Letter of Autho ati o sign permit_Encroachment doc <br /> EHD 29-02-001 — <br /> 6/22104 <br />