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r ` <br />San 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.sjgov.org/ehd UNIT IV <br />Well Permit Application <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 />WELL Location C01"t fir" G*% -(^W'9"Cr'oss Street 'Z5.0 City �R'�ftf Zip 93 7, Parcel# Assessors -2 5'-? O 3 �� <br />PROPER? p<✓j� -'.itll�3 <�R 1%����<O /�i7f3l�LI ��� i�r[JZ!!1 SZas <br />S •%C r/ Address City Zip Phone# <br />� �Y,l'Tia✓EZ 33 txr "".� <br />C-57 Contractor �E pA7/41/A/ddress 9�O 1L City Zi Lic# Phone �-� <br />-41 Q <br />Consultant / dress/ A G� Cif? ic# ' Phon #S <br />GIS Coordinates: X —'Y Township ��ltl�H Range S Section ! °' <br />WORK TO BE PERFORMED: <br />IVEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) D DESTRUCTION (choose type below) <br />/ D SOIL BORING # D OVER -BORE. DIAMETER <br />D WELL # /yJW D PRESSURE GROUT <br />D *Other { / GROUT SPECIFIC TIONS <br />COMMENTS: .� ni <br />tern a %✓eW Gj e�/ IVort-` ,/P <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING NfIHOLLOW STEM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS .$ <br />D VAPOR D MUD ROTARY DEPTH OF GROUT SEA <br />D AIR SPARGE/ OZONE D PUSH POINT (GP or CPT)GROUT SEAL PUMPED: <br />a SOIL BORING D HAND AUGER GROUT SPECIFICATIO0 <br />7-0 TYPE OF CASING: D STEEL X <br />VC D OTHER: <br />�a FrTREMIE TYPE TO BE USED: D AUGERS D HOSE <br />D No (NOTE: MAXIMUM FR E -F LL DEPTH IS 30') <br />D OTHER: fl OTHER APPROX. BORING DEPTH �S F%- D BOLTED TRAFFIC BOX or D STOVE 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 Ordinances, Rules as Regulations, and all applicable California State Laws. <br />�Y l crarsy Ei✓/fes E�`��✓�ER P`.r/,� -- d crt�i� <br />Signed x--- 3s ny Title/ <br />Print Name w 1"l«A,rc COPi Wdu Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By `z Date Issued Area <br />Grout Inspection By Date 41?7 ,07 Final Inspection By <br />Destruction Inspection By Date ^f <br />COMMENTS / CONDITIONS: G ® % <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />qVn <br />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 />