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U; F <br /> ILE COPY <br /> an Joaquin County <br /> Environmental`Health Department - SITE ­ <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> <lF�RN�P Well Permit Application UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y V b n <br /> Application is her by 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 /> WELL Location W. Cross Street City Zip C Parcel#Assessors <br /> t n �-"5 <br /> PROPERTY <br /> Owner h�le r �e� tll�` ddress C[ �J(? �,� <br /> city � ! Zip� Ph <br /> one# <br /> C-57ContractorT}�l �Ii Address 3223 -1 6& Q Ci SLP p, pin �C <br /> tYf [1,�..Zip lLic#D 1a��J Phon�# <br /> Consultant/Sub Cntr Address &/ City Lic#- -_phone# - 30 <br /> GIS Coordinates:X39-116 . - Y~)V Township = Range Section <br /> WORK TO BE PERFORMED >' r <br /> Q NEW WELL 1 BORING (CZ,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) *ESTRUCTION (choose type below <br /> ©SOIL BORING# VER-BORE. DIAMETER. $)S°� <br /> a WELL# " - �RESSURE GROUT ��� <br /> I]"Other GROUT SPEC IFI CATION ( G4 (?JOIE <br /> COMMENTS:-Owe" Q�I , StN' t it{�E�J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS s" <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS 0 MULTI-LEVEL .WELL CASING DIA:_ <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL .0 PVC D OTHER: �Q � <br /> Q VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS a HOSE �1 <br /> ©AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes a No (N.OTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTHa BOLTED TRAFFIC BOX or 9 STOVE PIPE .E <br /> .' CONDUCTOR CASING PROPOSED._ < (if.YES,list specifications In comment section). <br /> COMMENTS: � . ,.� - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 46 WORKING HOURS NOTICE REQUIRED FOR.-INSPECTIONS. n <br /> I hereby certify that./ have prepared this application and that the work will be done in accordance With San Joaquin <br /> County Ordinances, Rules and Re ulaions, and all applicable California State Laws. <br /> Signed x Title/Company � 04 (j J <br /> Print Name I`I G f -Date <br /> DEPARTMENT USE ONLY i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By 4 Date Issued Area (J <br /> Grout Inspection By to Final Inspection By 7 76 Dale <br /> Destruction Inspection By Date O <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID#; FAC# x <br /> k .. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> VJ5. 3053 (-r�- r� SR D�QZ3-r <br /> C-57 WC WAIVER i' C-57 Letter of Authorization to sign.permi —Encroachment doc <br /> EHD 29-02-001 WEB <br /> i' <br /> 9/11/2007 <br />