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San Joaquin County <br /> o Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> • •,,�Ir_ i!('2, 09).468.3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 1412 Well Permit Application <br /> 3 2G <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is het irrpounty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County l ii qll, rTq"t F �t 4 9-1115.3 and the Standards of San Joaquin County Environmental.Health Department. <br /> [" V���aGtr o L_ Assessors <br /> WELL Location y0 `y (JCOi�'I, Cross Street _1= 'J� City 57* Zip?f .3 Parcel# /y'S'/�—0'r <br /> PROPERTY �/ <br /> Owner 64 y Address.91'O 1`.; N/G401S City6017- Zip S�-VPhoneit� ag-I-,_ Derr <br /> C-57 Contractors/ AddresS2iL0 A), 4O0_ ST Cit44" ip �Z LicO .3 Phone# S.7vG�i f .Z y.Z y <br /> Consultant I Sub Cnt4!:';e6'A1?fe 46/ Addres 7 4 yC7r aIt CityHo,/ Lic#ygTC5_ _Phone# !W'? <br /> it�3 <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> 0 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 BOREHOLE a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS0fM TYPE OF CASING: a STEEL a PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL] -50W TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes FNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AjrSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS G G s s 9i- M AM i <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH / S a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> D CONDUCTOR CASING PROPOSED /N O (if YES,list specifications in comment section) <br /> COMMENTS: SP60 aTTGT* so c G�w /)�G ✓��Q'� <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 Regul ons,and all applicable California State Lawss..' / <br /> Signed x Title/Company ��'pf• r&%ng �y4se <br /> Print Name -5-re I e G r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 Z /ti WZia, tufa <br /> WORK PLAN DATED: t'S� Too 67"S(-- <br /> Application Accepted By Date Issued ZJ G Area' <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# R''EC'DD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> - "?fir s 7 ) ! L- r �0p SR#60 -Zj_ <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 />