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* Joa uin Count FILE COPY <br /> San9 Y <br /> z r � Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029MITIGATION <br /> n <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh #� <br /> a �P <br /> Well Permit Application <br /> MAP 1 Q 2008 <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. 711i�p��41�6 f4;reN. �i pliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental H � �'q <br /> �I� t'1 VL Cross Street 1 WV" <br /> Ocity S fOGk�a7/ o <br /> WELL Locationrs ���030 0/ <br /> y Zip�5 2b3 Parcel# <br /> PROPERTY <br /> we f04 <br /> tP <br /> On1 V,ro"61 Address2201 N- WCL5h\nL1k'nciitySAO Lk ()Y zipg5205 Phone#209 jq(o 02gl, <br /> C-57 Contractor A31- Address)_20 GaS t Jt • CityW (A Zip Lic#!QZ33y Phone#530'61 6-242y <br /> Consultant/Sub Cntr Wqf- s0 L) hV1P5 F Address 315 W, Ae_Sf#8 city ) c Lica Phone# .20g 33LI 530 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )/NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE !i MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Int TREMIE TYPE TO BE USED: 0 AUGERS tHOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes '(No (1 07E: MAXIMUM F5 EE-FA// DEP7H IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N EPer G../EIME wrr <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH E 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 Ordinances2g�4L <br /> Rules and Regulations, and all applicable California State Laws. '` <br /> Signed x /1 ate(, Title/Company qeol o'i IS f / Vv qp, G <br /> Print Name �Yv heeho�r� Date <br /> DE'P_AR_T-M/nE�NT USE ONLY Z9 So <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /Vl� N � ��.� <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 3 3 0 P Area D <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 CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> e%,a. .. SR# 05 Sg L <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N A <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />