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San Joaquin County 0 <br /> E WED <br /> Environmental Health Department SITE <br /> Dal <br /> 600 East Main Street, Stockton, CA 95202-30q%,- 1 0 2007; MITIGATION <br /> -3449 Fax: (209)468-3433 Web: .vxvNv.sjgo,.-.org/ehd(209)468-3449 UNIT IV <br /> ENVIRONMENT HEALTH <br /> Well Permit Application <br /> PERMIT/SERVICES <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 t'1115.3 and the Standards of San Joaquin County Envi onr9ental Health Department Assessor!,,�6/�, <br /> )z�6 all",,, , W'12 . ?,)'. <br /> WELL Location (.'14� ross Street ZiptW_2Parcel# <br /> ,PROPERTY to Ct S . : <br /> _t <br /> Owner Address C/C,6C7-�' it rNa44�,, Zip_jjSakPhone# <br /> +CZ <br /> r <br /> C-57 Contractor W\d D.6111kU Addresspo_&7 (Mo _CityL��iZip��Lic# Ph.ne9,b9'12& ,94k <br /> Consultant/Sub Cintr9leaAayl 71—-Addres4OZZ5 dCit Lic# Phone#-Z�"N2'&!k <br /> GIS Coordinates:X Y Towns/, Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) []DESTRUCTION (choose type below) <br /> SOIL BORING# []OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> &*OtherGROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM DIA.OF BOREHOLE � <br /> 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA:,z <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL ,*VC []OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED: OAUGERS 0 HOSE <br /> AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 1KYes []No (NOTE: MAXUM FREE-FALL DEPTH IS 30') <br /> SOIL BORINGHAND AUGER GROUT SPECIFICATIONSVeo�_ <br /> 'kOTHER-Pj'6i�Q��;OTHER APPROX.BORING DEPTH I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES I' t specifications in comensect <br /> iQ_1jjPAL& )kl I f 0 4 <br /> COMMENT&- /I') /42aw b 424'aeg <br /> 1/7- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. N <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> O <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin _4N <br /> d- <br /> r i <br /> County 0 ances ules and RK dations,and all applicable California State L s. <br /> _9�gu a L W <br /> Signed Title/Company/ <br /> f <br /> Print Na�j&j�j Dat/z:g /Qme <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: � 0105 15. (l DIA A <br /> WORK PLAN DATED: 12- (1-2 (0-7 <br /> Application Accepted By Date Issued 172- 7- Area <br /> Grout Inspection By —Date 11 1 10 V' Final Inspection By —Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT SERVICE REQUEST# INVOICE <br /> -c'C' 13 2- SR# <br /> C-57— WC--WAIVEP, C-57 Letter of Authorization to sign permit,,/ Encroachment docv"" <br /> 171[D 29-o2-ooi WEB <br /> 9/11/2007 <br />