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I , ,an 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 /> .. _�•f U jR� 5 37 Assessors S 3 D 3 0 <br /> WELL Location C"!/RRf�L am` _Cross Street City r Zip Z Parcel# <br /> GA'�✓O i'/G G q � <br /> PROPERTY yvZi/p $Ohone# -��!J <br /> O�wrner.r4^1U0! <?"1A/ 11 .dOddress�8�O Un//A /HA2 EC%O�✓ J/ Zi �' <br /> C-67 Contractor RE OCCAddress ♦ro!yN✓F �� City -Zip Lic# Phone <br /> Consultant/ x1g1li✓ Addre/ /•�lUr.../ -` _CitZ4y0✓y„Lic# Phone Vj-f 2-rP <br /> GIS Coordinates:X Y ,Township 3 �R'`�`� Range S Section <br /> WORK TO BE PEI RM �� 0 <br /> BORI CPT,GEOPROBE,HYD UNCH HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> Q SOIL G# 1 OVER-BORE. DIAMETER <br /> Q WELL# —�' Q PRESSURE GROUT <br /> Q*OtherGROUT SPECIFICATIONS <br /> COMMENTS: /CP S'O/�Bd✓�=I JC c�G✓ �1�� LUs/�f L „S'r./�ds./ 7roz+ a✓ '�.� p�:J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING `VHOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL ''75 /r-7 TREMIE TYPE TO BE USED: Q AUGERS Q HOS <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED:Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING Q HAND AUGER GROUT SPECIFICATIONS N�Rf C(Mrwr <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH 1':7 Q B LTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTORASING PROPOSED 06 (if Y S,list specifications in comment section��C <br /> COMMENTS: /C/I7 f►U+��✓� /' S� T//lGd G✓//?G° G�G"/Y/t �T'j C6' O✓G eeL <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 and Regulatio d all applicable California State Laws. <br /> Signed Title/CompanysE�`7 —PAA0 — •C,0Qf0 A/C' <br /> `sl' 7 �L �ilR/e�G /✓/ / <br /> Print Name Date !J <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: //��_��_ /') <br /> Application Accepted By ej ��Ar' d4Z4 '741", Date Issued Area_ <br /> Grout Inspection By a-A-Le mate // Z7l©7 Final Inspection By 1614 �/ ate �8�7 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 S R#5c �r' 5:-3 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/1112007 <br />