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DD <br /> C 1= L <br /> 01u 3 2008 San Joaquin County <br /> , . pronmental Health Department SITE <br /> Z0NIvIBT N06' ast Main Street, Stockton, CA 95202-3029 <br /> �.-��,.4-' MITIGATION <br /> P MIT/S266�-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 /> Assessors <br /> WELL Location l9 o tf 4feh�r Cross Street S City 5rl4- Zip9fg?o Parcel# /y5 <br /> PROPERTY �1 / /.� <br /> Owner S/jfr�0o AOC /(_ AddressY,1� +411 City&0114s/� Zip90(_,?hone# <br /> C-57 Contractor_ A S Address-�M ,gj�OzZ- St Cit s'�` <br /> /'- / CC '/ i&Zi ic#V.W Phone# S3dG�.9",?y�y <br /> Consultant/Sub Cntr� `!Ott Jfnf!/ Address��7 Alete- 0y city A Lic#J.� Phone# 5V? 0179.3 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE4_45'a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS /4 Al TYPE OF CASING: 0 STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL-4 i17' TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE APUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes j rlo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS C,&S S G ^y 7-- <br /> a <br /> a OTHER: a OTHER APPROX.BORING DEPTH S' a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED/L/D (if YES,list specifications in comment section) <br /> COMMENTS: 5 P t° e-7—M G4 r 5&,$.'41., <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 Regulations, d all applicable California State Laws. A <br /> Signed x Title/Company //�J_ G►�d/�4 aJ t �'k!/ <br /> Print Name d Date�� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 . Wau� <br /> WORK PLAN DATED: Q, /S-i 201 ' p <br /> Application Accepted By Date Issued L S10 K Area a I� <br /> Grout Inspection By Date Final Inspection By Date <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 /> 220 Ly t 17 7 <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 />