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FILE COPY <br /> 0 <br /> I I San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street. Stockton, CA 95202-•029 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjaov.org/ehd UNIT IV <br /> 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 Joaquir,County Environmental Health Department. <br /> WELL Location -> r tyfet, Cross Street _City JkZip 4 AssessorssOQ1�C7 <br /> 3 <br /> PROPEYI <br /> Owner k Address V CiZip�Phone#QU> 3q7. p s <br /> C-57 Contractor fflrcts.>a <br /> yrm"jIN T+ Address I 0 7 f 4 ySG,c �4,- < city Zip 't'NJO�hic#c'3c.3 phone#���-6 71 -V 7`fY <br /> Consultant/Sub Cntreo ..df',k t.z+nculr<ir /7,Address l20 !^, 411,via1 City Lic# Phone# y `�S5 <br /> GIS Coordinates.X 3T*0 Y-121.29 I Township Range_ __Section <br /> WORK TO BE F_gRFORII MD <br /> $NEw WELL Fe�RING---/(CPT EOPROBE YDROPUNCH,HAND-AUGER.OTHER-) DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT /. <br /> // Other tL, 4 --/t f- r-Cy fpr l DGS. GROUT SPECIFICATIONS f reM(� <br /> Lkt <br /> COMMEN S: ( S Ic 41 6e col(ecte Sr sever-;5:4 ctf seveQ /occL:hci7.t' "+0� <br /> ^� 5 o G - r r r rGA ho(- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> v{_ 0 MONITORING Q HOLLOW STEM DIA,OF BOREHOLE Q MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> XTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> 4", 'APOR <br /> Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br /> \,__g'AIR SPARGE/OZONE Q PUSH POINT(GP orCPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER Q OTHER APPROX.BORING DEPTH- <br /> Q BOLTED TRAFFIC BOX or Q 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 /> r <br /> Signed x�(�r r r � Title/Companyn*/ <br /> Print Name /?ff', �Gf/ C(l _ Date 1 G) -5 `0 7 <br /> DEPARTMENT USE <br /> ONLY RW 13.uST <br /> SITE MAP IN UNIT IV FILE, ADDRESS: gt*R <br /> WORK PLAN DATED: /n <br /> Application Accepted By- -- - - - -- - ';are;�c � �:—!_ 'd ;;.�.a Q(QQ T <br /> Grout Inspection By - Date Dae _ <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 I SERVICE REQUEST# INVOICE <br /> 2-10 7. 13.p7- S R# 0 S Z L I �! <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD29-02-Ml WEB <br /> 9/11/2007 <br />