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San Joaquin County <br /> z <br /> NED Environmental Health Department SITE <br /> { 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 0 5 2OR6)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> lNIENT HEAUkt Well Permit Application <br /> PERMIT/SERVIC-FLN-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 /> Assessors <br /> WELL Location I �i�Il W � Cross Street City Zip ISS Parcel# 1 3 1 1 ZO O q- <br /> PROPE Y II h- / <br /> Owner VfTia'/ tii� Address .I�taJJ�C _City Zip �f'hone#/v'Z �l"flp�'�i � <br /> C-57 Contractor /� ddressl:� IJVX.�� City4" Lic# IW Phone# <br /> Consultant/Sub Cntr N/1� Address City Lic# Phone# <br /> GIS CoordinatesX Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') XDESTRUCTION (choose type below) <br /> D SOIL BORING# OVER-BORE. DIAMETER <br /> D WELL# rPRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTSOJe-�Do�I I YVJ W-fj, jj <br /> zI -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING -�*0LLOW STEM DIA.OF BOREHOLEJI D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS.4o TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL .v a' TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS CC y^ZA/k7f <br /> D OTHER:_ D OTHER APPROX.BORING DEPTH 15 D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:_ <br /> r It ll f� l sr <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 O/rrcl /,annces,Rule a d Regulations,and all applicable California State Laws. <br /> Signed x <br /> AAA cti Title/Company 1��t d✓ r <br /> Print Name ate U/! �/(j <br /> 11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 14 Z I-() IA)e%+ S4,a& IZp,2ju y <br /> WORK PLAN DATED: Qf� <br /> Application Accepted By Date Issued htArea <br /> Grout Inspection Byy„n .,v� Date Final Inspection By ���_Date <br /> Destruction Inspection By Date <br /> COMMENTS[CONDITIONS: 01(.Q Ili " (a,l e,%A Qh1 0-n Cf—Z" <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2*to l -460 ,00 b62o U�_ 6'II Jot SR# S T 5 3 <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 />