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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 /> E' 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 /> ��$ U %iPAGy S 37 Assessors 12 53 v 34 7 <br /> WELL Location 6!11?R14L /ti'fl2 Gds✓ ' '_Cross Street City / Zip 7 Parcel# <br /> LA�✓D FiG L <br /> PROPERTY ity <br /> nerS�n/t/O!4Qu//✓ AG°' /�/¢2EC/4�GJ -p'Zip �'S Ph <br /> O ddress/8/0 one# 2"V%7 � <br /> 3�3— SSW <br /> C-57 Contractor RF O0/CC//j/1jrAddrea�® <br /> ss / &We /CA City -Zip Lic# Phone �J' <br /> Eir✓✓i,Pd�✓iltE�✓i.A� �� <br /> Consultant/8vb'CM-.r1g11 ✓ Address AW C, City�v�� Lic# Phone 9 2(-e <br /> GIS Coordinates:X 'Y ,Township 3 Range S Section <br /> WORK TO BE PERFO llA A* <br /> ORIN (CP- GEOPROBE,HYDRO CH HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> Q SOIL #_/�P ter, Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q*Other 1 GROUT SPECIFICATIONS / <br /> COMMENTS: /efrZ .f"(!/�&�''� r %� c�G✓ /�� L�!/T�� C �'`./ r -a u✓ '��oYr�i4.J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW 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 -75.1r-7 TREMIE TYPE TO BE USED: GAUGERS 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 301) <br /> OIL BORING Q HAND AUGER GROUT SPECIFICATIONS Me*'F <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH "7/0 B LTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR ASING PROPOSED 7Q C 5 if Y S,list specifications in comment section <br /> COMMENTS: IC�l7y+�w•' 9� delll�d G✓ .rl c° a tr j'a !`1 owe /��E'n <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 x Title/Company.sEA// _Cd 190 <br /> F���/t/��/� -" P/✓,D <br /> Print Name A/- /"1 eff11qLEe- 'C�dZ6 DateZdZ" <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / <br /> Application Accepted By �` �� Q Date Issued Al 9/'0 Area <br /> Grout Inspection By 109%- +Dateh Final Inspection By �ii' ate <br /> Destruction Inspection By Date vh <br /> COMMENTS[CONDITIONS: Lgll..8L07^ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 7/ 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 />