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u U U <br /> 2009FILE COPY <br /> .: UL <br /> San Joaquin County ENVIRON1v1EN, -HEAL/H <br /> Environmental Health DepalrtmentpERMMSERV4GES SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> ` (209)468-3449 Fax:(209)46873433 Web:www.sjgov.org/ehd UNIT IV <br /> Well Permit Application `' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D 11C� 3 �YL <br /> Application is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This applicatlon is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-9115.3 and the Standards of San Joaquin County Environmenla!Health Department. <br /> WELL Location laz-6-U 10 W C 1 f„j Cross Street 161In1-6-m JZ4 <br /> �YCc�Lri;:7F,s <br /> City 1 v om'! Assessors <br /> PROPERTY p �bg Parce# <br /> 00 1 ­2-3-7- 0 <br /> 3? <br /> Owner i hVCiV-C A Fore A Address NLr-City Yc+r� ASZiP-±-q 25 Phone# (a1 4 -30 -(cl tm I <br /> c-57 Contractor_WDNi 0✓ V;11;." Address t 0 0R 3� V City-LIy' S'-lal Zip 4+571 Uc#7100 Phone# :jE:j 3&`74-430 0 <br /> Consultant/Sub Cr>ir ICES Address &300 aw�lls+ In I �rI'> Ce <br /> 3%. 22 0 ty !iG# 3q-7n7 Phone# SID-b52 3222 <br /> ^v.5 Coordinates:Y. 5 ,.. 4j2-(.q j o ,Townshfp Section <br /> Range <br /> -MftK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) I�ESTRUCTION (choose below) <br /> 0 SOIL BORING# 'COVER-BORE. DIAMETER ri <br /> 0 WELL# ,n PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS. <br /> COMMENTS: MVI 1 M W-2- <br /> TYPE <br /> -TYPE F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSN)WN • + �., <br /> MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL {HELL CASING DIA: { <br /> 0 EXTRACTION 0 AIR HAMMER/DRiVEN CASING THICKNESS TYPE'OF CASING: <br /> 0 STEEL 0 PVC 0 OTHER: �y <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED: B AUGERS Il HOSE V <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER;__ n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: w <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 Inancess Rules a))nd��Regulations,and all applicable California State Laws. <br /> i�l �. <br /> Signed x I ll/t L�. 4 Title/Company YD Q � � I C� . <br /> Print game W t t t .Date <br /> 4 DEPARTMENT USE ONLY; <br /> SITE MAP IN UNIT IV FILE,ADDRESS' <br /> WORK PLAN DATED: nese T <br /> Application Accepted By Date Issued Area <br /> Grout Inspection BY Date Fina!Inspection B.0 <br /> Destruction Inspection By Date l Q ' <br /> COMMENTS 1 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� �S� �F� � <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02.001 <br /> &R2/04 <br />