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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 /> :' <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 /> el- <br /> 7Sfy `^ J S3?1 Parcel#Assessors D 5-31 3D/ <br /> WELL Location eIIRR�f: �OLGd� ' _Cross Street City / Zip <br /> 6.4A✓O <br /> PROPERTY '� /8 .FSE "�S2,o 'o��L6��3'066 <br /> O�yners�n/�IOAQc.I/n/ G'!nA✓ ddress /0 �EC/dam City � Zip hone# <br /> clL/Q ✓ifi .K.4�iC%/i✓�cL' 9 ..S <br /> C-57 Contractor IT" ((//✓Address /QFO&We xe ) City _ ip Lic# Phone <br /> Consultant ISutr t'ftt"*SiC/ �Lic# P <br /> i9/✓ Address 6LV— City' hone <br /> : <br /> GIS Coordinates:X �( 'Y Township 3 YnAoa Range 5 Section /� <br /> WORK TO BE PERF '"- f4- <br /> -t/ ORING CPT,GEOOBF,HYD UNCH HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> Q SOIL B // _ _ a OVER-BORE. DIAMETER <br /> Q WELL# a PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: %�P •rel �`''�f� �'•1c��j G�! sig�� C'y��� C�' s-`./�'e��f.-oz-��✓�+� .J"o�frJ <br /> TYPE OF WELL -INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING STEM DIA.OF BOREHOLE o MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:_`�� <br /> EXTRACTION �HOLLOW <br /> IR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC o OTHER: i✓�i�3 <br /> ®VAPOR �.MUD ROTARY DEPTH OF GROUT SEAL '75 /�TREMIE TYPE TO BE USED: 0 AUGERS 0 HOS '` <br /> ®AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:x Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> OIL BORING ®HAND AUGER GROUT SPECIFICATIONS C,(MIrAlT <br /> ®OTHER: OTHER APPROX.BORING DEPTH Frf BONED TRAFFIC BOX or G STOVE PIPE <br /> _ JCONDUCTOR ASING PROPOSED ,1j A if Y S,list specifications in comment section <br /> COMMENTS: �C/I? O*�A✓ 17!/✓i� 74 de YIGO/ G✓ I/�° fG 9 !�1 4✓G /��e'�► <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 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/CompanySEY�/ —RAJA <br /> Print Name �` /tet l e&117-E-c- 451f /e 6Z Date d4e <br /> ll,11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By f � �^�°"' Date Issued '�! Area <br /> /G Date Final Inspection B ,�/ ''< 1 V " ate ' �8 d 7 <br /> Grout Inspection By ��P ��°/� f/�2$l®7 y ! <br /> -/" <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: /,-)//1/0-7^ r Gfl0nL <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 71 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 />