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• P* Iv��Ebl <br />San Joaquin County REC <br />Environmental Health Department OCT 2 200 SITE <br />600 East Main Street, Stockton, CA 95202-3029 JOAQUIN COUNT'MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.oV IRONMENTAL UNIT IV <br />Well Permit Application HEALTH DEPARTMENT <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 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 />tt t Assessors <br />WELL Location 34'12 't 1 `�l- Cross Street i �``' � �% City �)L f.Vi Zip Parcel# 0_"- b .,NA <br />PROPERTY n ✓ �k' J <br />Owner 4Z`Y(" ti ftp ��, t`�` Address '2 t t ,�rl� a H" ch CAt City Lr:�A !f� Zip iZ7Phone# : j f - <br />D <br />C-57 Contractor `�� y ll� Address Ci Zip Lic# $� Phone# <br />1 }�,- .112.`) <br />Consultant /Sub Cntr 11`h 1 tit' vi/1+� ANJ Address Su j+e. ?PX) CitvJ.1A Lic*-t3S0(m Pt,nnr># <br />GIS Coordinates: X —1-2C `l VI ldo.Af Y ySOy fit; Township i <br />WORK TO BE PERFORMED: <br />EW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />WELL # <br />Other��ii tail I�nt+<s �t rj\k�ir St <br />COMMENTS: - - A a 1 11 iiveig ik'I <br />Section <br />p DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />hu i/_ / '�— X'Q <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS p <br />0 MONITORING )<iOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC OTHER:414–Kt' <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM �FR�.E.E-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS piiyit.� �x Vyf ta <br />1.+i \,y{i <br />bTHER; l`C'tl" 0 OTHER APPROX. BORING DEPTH0 BOLTED TRAFFIC BOX or STOVE PIPE <br />/ M1 i CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS:' _ 7 TT <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 Ordinan s Rtiles and Regulations, and all applicable California State Laws. <br />Signed x TitlelCom an Flu <br />Print Name Date L% i f✓i <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By/�' � f Oft 7�`^��'c �� Date Issued �D d Area <br />Grout Inspection By -4'�r' 'CO :'� Date Final Inspection By i <br />Destruction Inspection By Date <br />COMMENTS ! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT! SERVICE REQUEST # <br />INVOICE <br />�S <br />73 1 -c)111- <br />i°Iv Of" SR <br />C-57— WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc� <br />EHD 29-02-001 WEB <br />9/11/2007 <br />