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000284 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main I Street, Stockton,CA 95202-3029 MITIGATION <br /> •', (209)468-3449 Fax.(209)468-3433 Web www.sjgov.org/ehd UNIT IV <br /> .1 <br /> c `�'- %'r� 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 applicatlon 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 /> ff�� Assessors (�y LHL(v <br /> WELL Location E-A)t Yin( 4j CLS Cross Street v City /-t)jl Zip Parcel* a-g1YDiZ <br /> PROPEKTY <br /> Owner l mde.tii No-:L +tit:; L1 Address F0 DO/, � 7`0 City jL,Lt1'•1 Zip. IZ!7 Phone# <br /> ����11 <br /> C-67 Contractor r Address i(/ f Y-;� %�'!`� City Zip r"r Lic# Phone#_ "3U <br /> Consultant/Sub CntruEtpK —Address4w w 1' h C; terCity y ( LIc#-7/7007 Phone#.7 , (l <br /> GIS Coordinates:X b-�3<✓G], 7 Y 1�2Z) 7 O,0 Township L fy,rA Range 7~4}t Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') G-6ESTRUCTION (choose type below) <br /> a-SOIL BORING#2 Q OVER-BORE. DIAMETER <br /> &WELL# VRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> X111 t <br /> COMMENTS: / ,1 1"'WW Lc7w11'l;f,^c>l '25 LN2,C Zr4l:�n P�Sy✓r gP'6uta Ai G%+e% a r�� 4-lwr <br /> TY OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING Q HOLLOW STEM DIA.OF BOREHOLE 7•rr Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:1 _ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: Q STEEL 0,<C BOTHER: <br /> Q VAPOR p Myp ROTARY DEPTH OF GROUT SEAL — TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE SH POINT(GP or CPT)GROUT SEAL PUMPED: es Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER:_0 OTHER DPT APPROX.BORING DEPTH 78� 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 /> Signed x �n Title/Company �rt ,e Ct af4 AAa c1t✓ ^Ut PI �C <br /> Print Name � �N�iw Date <br /> DEPARTMENT USEONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -'3-75-0 <br /> WORK PLAN DATED:_ <br /> Application Accepted By - Date Issued IJZS-1 o 7 Area�Z{2— <br /> Grout Inspection By to 114 Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: /k0 CLt (101 1315-S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �!D p yf D �j i�/s�o 7 SR# S7 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/1112007 <br />