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0 • <br />San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors 2� <br />WELL Location 32L{� S.LI I�/ctl�Q 5"t�"�F Cross Street 1% i1/e City Sfit{ Zip9SZy�O Parcel# I?7(�W <br />Owner PROPERTY at( �VU D S "1S2 �/ �) l��j^ <br />Owner( DV�E' C,����r���iAddress vf�- City ��i Zip�(Jlfi1VPhone# <br />q5 t) VOLA City p -1`I Lic# jUS"P` q�'� 3-5800 <br />C-57 Contractor � r � �( Address Ci �+ti��Zi Phone <br />Consultant /Sub Cntr 1 il�r Ei1Ut AddressAaLi 1'�fMn 5r !, ;,e?r�kity Lic# -i5 Phone# <br />t4-6iYI-S�ISL-J <br />GIS Coordinates: X �120�yti LA sb t , Y :W 01" ,Township Range G Section <br />WORK TO BE PERFORMED: <br />J�<4EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") p DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />"Other &(y pro(pe— GROUT SPECIFICATIONS <br />COMMENTS: -- ,k <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z)- /.t <br />0 MONITORINGIOLLOW STEM DIA. OF BOREHOLE ,MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING pIA: <br />EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS (/ , PE OF CASING: 0 STEEL ,KPVC 0 OTHER: <br />�/APOR 0 MUD ROTARY DEPTH OF GROUT SEAL Set <br />—ay PE <br />TYPE TO BE USED: ,UGERS 0 HOSE <br />AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �� .t(1 / J04 ( y <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH S 0 BOLTED TRAFFIC BOX or 9STOVE 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 Ordinance ules and Regulations, and all applicable California State Laws. _ <br />— — -� Ul �7yn Irk <br />Signed x �i� ^ Title/Company 1P,V �r (�!L_�J <br />Print Name s Date <br />DEPARTMENT USE ONLY <br />PAYMENT <br />SITE MAP IN UNIT IV FILE, ADDRESS: RF o FIVF=r' <br />WORK PLAN DATED: <br />/ P Y6. �%z3 � 1 9 2007 Area <br />Application Accepted By :�.�� Date Issued <br />Grout Inspection By aBs y �1t 1 Date �Final Inspection By <br />Destruction Inspection By Date ENVIRONMENTAL <br />COMMENTS f CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # INVOICE <br />4y—L <br />�I`t <br />711410� SR# QO ��3 `49 <br />C-57_ WC '-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001web <br />6/22/04 <br />