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. San Joaquin County <br /> r <br /> Environmental Health Department it j c'1 ;`�,`, ,SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/chd ASAP„ , UNIT IV <br /> �qG i F...... <br /> RN\P <br /> Well Permit Application <br /> / n <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED r+ I msfy 4�I IS <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--11115.3 and the Standards of San <br /> San Joaquin County Environmental Health Department. <br /> WELL Location 2132grLq 35 �I77SNIq lo`n 5'� Cross Street 7h� Unvr Ci '5-6 j Zi SZct Assessors lKS^o2-17 <br /> T—� ty 7 I OC-F'�'OL` p�f 3 Parcel# I KS-o2- - 7 <br /> PROPER (� LL -42 <br /> 1 I � I,� F' <br /> Owner U�/0!' StAlvh Address 2201 Wit/W�jSry ou��l City SNCI1�T"`t Zip 9sU3 Pho(n/e# ZOy- !l"�6-�y6 <br /> C-57 Contractor bog N,1 Address rSD rnlwe d� Ciry A4-'M1L Zipg553 Lic#7S5'4�SPhone#9�5-313-55c- <br /> Consultant/SubCntr E2h1 •WevilTac. 2SZ5Na woo <br /> AdtlressDnvpr rr�o Fmk Ciry crAwx1+Lic# .NA phone#116-W--W-V-937,9Y-�37 <br /> GIS Coordinates:X ,Y ,Township JCC TIoti g Range 6� Mf 01590 Section <br /> WORK TO BE PERFORMED: <br /> `at EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> fl SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# OW-1tkrpyeUt. W-l� aPRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: 4 we 115 /2�rdviwlrit--) -I, hr (1,S�164 Via ftSA _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ` Z "M >R <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE o B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS5Jx `10 TYPE OF CASING: B STEEL '/'FVC B OTHER: <br /> B VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ^ Lr+ TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> B AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: B Yes yNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING u HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH —11 �ee} DtOLTED TRAFFIC BOX or B STOVE PIPE <br /> 1 //1J CONDUCTOR CASING PROPOSED 1.r�10 (if YES,list specifications in comment section) <br /> COMMENTS: qAt LO( I(Cal , 12-'rlj &-. C 5 eAP,( AA /2.-� 'YIr9s l dll ( n..� L, A" <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 re ared this application and that the work will be done in accordance with San Joaquin <br /> County Ord'h nc s u etan Regulations, and all applicable California State Laws. t L <br /> Signed tt Title/Company �Nro" ctojow`0 I_R�1 'w�A �HC• <br /> Print Name Melff Sct ,erfl"* Date 3ZO vS <br /> DEPARTMENT USE ONLY n <br /> SITE MAP IN UNIT IV FILE,ADDRESS:(& (✓• �✓kS�i >,rt�7o. SF- Yi Lt A l c� <br /> WORK PLAN DATED: &)pt). Zpo") <br /> Application Accepted By��yL��� Date Issued 3/2 0c,; AreaZ <br /> Grout Inspection By /�I�wvtil Da te-Sf It 6'9 Final Inspection By Date <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 tPERMIT/SERVICE REQUEST# INVOICE <br /> #DO�� 8 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9111/2007 <br />