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aq"'" San JoaqA4111. <br /> Count y <br /> COPY <br /> �l, r <br /> Env,ronmental Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029lNg'N - g 2008 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgv. Ghd <br /> �P �fV�/��tJf�liv1EP1T HEALTkj UNIT IV <br /> Well Permit Application PERMIT/SERVICES <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 /> Assessors <br /> WELL Locatior C <br /> ,ross Street ity9C �,7� <br /> Zip d7 Parcel# <br /> PROPERTIY <br /> Owner L TC-1-LIV3 neOC-7i.1,CAddress2377 eFF-�i4wP -u0 <br /> city TA0ANC Zip l <br /> Phone#a/y' 4 /8•U69$ <br /> C-57 Contractor gSffveLGNE / SAddress � c05-# Sae� City GC� �ip`, 7? Lic 'Z33` Phone## 3t -�E <br /> 0Z <br /> Y <br /> Consultant/Sub CntJl Adddres h1A1T)q , r//j-F_VCiA fp ?c# Phoneg%•977-P,75- <br /> GIS Coordinates:X 3-f.7% ,Y-12-1I• !(13 Township 02-S Range 6 41E Section / <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING . {CPT, OPROBE>AYDROPUNCH, HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> / OIL BORING# j 5 aOVER-BORE. DIAMETER <br /> ''][ WELL# r,RESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS:. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING []HOLLOW STEM DIA.OF BOREHOL6.LS MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA:-"-- <br /> a <br /> IA:"__[]EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS � TYPE OF CASING: 0 STEEL []PVC BOTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL / TREMIE TYPE TO BE USED: p AUGERS NOSE <br /> a AIR SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes Vo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ySOIL BORT G []HAND AUGER GROUT SPECIFICATIONS /V t-F11 G =/'elf jV'T <br /> ` JTHERIV ✓1/r/ . o OTHER APPROX.BORING DEPTH C _BBOLTED TRAFFIC BOX or Q STOVE PIPE <br /> (ALL CONDUCTOR CASING PROPOSED N (if YES,list specifications in comment section) <br /> COMMENTS:_(`SCO epu6 L kr-W65 W[L< "AAVEWIVIPPAWI Vy6-VI, (}4' 15 (LIN$ �1 pK!✓V�,(t�� <br /> 0( fpP-SGP-OFN A17 P(c 6A'3/A(o <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby ceT <br /> at I have prepare this application and that the work will be done in accordance with San Joaquin <br /> County Ores, Rule and R ulations, and all applicable California State Laws. <br /> Signed x / ^' ^ Title/Company <br /> Print Name (�f� �( .� /L�H 7 /C)6 <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_ I�PL !<i- <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued `S - Area 0b <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED sPe'rw ViS REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2�0 zs� 45 16 ,Ig sR# 4,<3�/6 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 WEB 441 <br /> 9/11/2007 <br />