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o qU I -man Joaquin County <br /> ` Environmental Health Department SITE <br /> 46VEast Main Street, Stockton, CA 95202-3029`3MITIGATION <br /> (aQ9)14¢ �9 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ' CFO 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 Joaquin County Environmental Health Department. <br /> 1 Assessors <br /> WELL Location 1296 F&4 M" L AM4 Cross Street Utx� La,-.c City Ickjoi, Zip .F21 Parcel# <br /> PROPE TY <br /> Owner Address 76 TroA'va.a. City�i ru^eK�» Zip Tlrhf Phone#('M6) 5-6-5'- 70(Cy <br /> C-57 Contractor �6aa h 7..e Address 3632 once C.rd, City ip JA70Lic# Phone#(y6o678-//6y <br /> c <br /> Consultant/Sub Cntr 56caal2 TM{- {,o,,c.Q Address3o,7 K.(,,Orr 1 �ttip City" c# Phone#6tM $(/- O Y�O <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 3'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER") 0 DESTRUCTION (choose type below) <br /> O SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# M&-/,mw-2 MIJ-Y /rlFi-,/ 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: /`y, SECo%LJ cJ#rkf& /�/dNlfiri�� <�� �a54wjoh ',�c�-'OI <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSE(. YO TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL 30 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: O Yes ON (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �Jtu LGw <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH SS 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 Ordinanc , Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company //t/J <br /> Print Name -glr/V 141C1($17"C. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1w, Lawes <br /> WORK PLAN DATED: <br /> Application Accepted By _Date Issued 'Sk1 Area 3G t t'1 <br /> Grout Inspection By Date Final Inspection By 41L4S Date S`ii 08 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 g o t ,o qq.o J -)Sol.541}- z-t (, S R# 0 0 5 3 <br /> C-57L/ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 WEB <br /> 9/1112007 <br />