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Qn Joaquin County <br /> K 7 2008 Environmental Health Department SITE <br /> " T HEALTH04 East Weber Avenue;3rd Floor, Stockton, CA 95202 MITIGATIONw <br /> of ERVICE(709)468-3449 Fax:(209)468-3433 Web:ww.sjgov.org/ehd UNIT IV <br /> lib' Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4 Application is hereby made to San Joaquin County for 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 /> 7 Assessors fi "f w'Y <br /> WELL Location 1 0 6 �✓ fro v+1/ Sf' Cross Street S-f'r C�r�rn Qty �,' or+ Zip y S�G6 Parcel# <br /> PROPERTY q�City �'�oN Zip 9Ssa Phone# 909-599- <br /> :I Owner ( 144 o-F � do Address 25-9 N �.t,) /vr'o <br /> Y8 5/6f171 i <br /> C-57Contractor (,/ry� 0+ 11'nth/ t(ddress 15.0 yln wK IeJ. Cey.Morti.'+ir Zip?Yfr3Lic# P one# -- Tl4-.f8oa <br /> re IA - Uc# — Phone#-�09-S79-JJJ/ <br /> `Consultant/Sub Cntr 4T( f}ffa ri+�f Address 1117 Lursr /gl �• City <br /> .GIS Coordinates:X ,Y ,Township S Range 'd'E Section 3 CJ <br /> i <br /> .. <br /> WORK TO BE PERFORMED: - <br /> ' NEW WELL/ BORING (CPT,GEOPROBE HYDROPUNCH,HAND-AUGER OTHER`) ll DESTRUCTION (choose type below) . <br /> SOIL BORING# 1 <rh7s.l - !�T - D OVER-BORE. DIAMETER- <br /> --L-a WELL# . a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> :'.COMMENTS: I' <br /> i <br /> i <br /> 4 TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i.u MONITORING• a HOLLOW STEM DIA.OF BOREHOLES b°1 a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA:_ <br /> a EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS Nil' - TYPE OF CASING: 0 STEEL ll PVC a OTHER: <br /> VAPOR g MUD ROTARY DEPTH OF GROUT SEAL` TREMIE TYPE TO BE USED: D AUGERS n HOSE <br /> a AIR SPARGE/OZONE •PUSH POINT(GP or(PnGROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> .'JXSOIL BORING - a HAND AUGER GROUT SPECIFICATIONS 100 - e4 fi, jV dV4 S)v e r y <br /> DOTHER: aOTHER APPROX.BORING DEPTH TBD /0o-ISO f10BOLTED TRAFFIC BOX or QSTOVEPIPE <br /> CONDUCTOR CASING PROPOSED u - (if YES,list specifications in comment section) <br /> 'E COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> "I hereby certify that 1 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 /> Signed /L1i � Title/Company 1Pr4,j,,Z4 Gtologisf 1A7-e Affon,I+s?nr. <br /> 'i Print Name Date <br /> DEPARTMENT USE ONLY L <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 10 (o' W e.%+ S le C D h J S+Ye o f __ <br /> !'WORK PLAN DATED: r (Lt�27W (n1 700 8 <br /> Application Accepled Br' ,dLsJ //lC lirl/—�7—Date Issued '- 2) - 0 Area 4 5 9 <br /> Grout Inspection By Y,t*m-:n L.I11n,/r Date //h,21-09 Final Inspection By VjtLJXdAj), -itL., Date <br /> Destruction Inspection By I Date � _ . <br /> pp COMMENTS I CONDITIONS: - ' <br /> j ACCOUNTING ONLY: AID# FAC# <br /> ;i PE CODES FEE:INFO AMOUNT REMITTED . CHECK#' RECD BY:I DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3sal85 00 40 <br /> 3 4, 00 5 03002 `�m /0 21-DS SR# U05S 21. <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 - - <br /> 6/22/04 - <br />