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oo San Joaquin County <br /> a <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ��-2(�9�468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> 3 2608 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicati�g,t4ptjeby:m�d, to ;jan, oagwin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Cokr)4y Qwplb i> fltte,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental,Health Department. <br /> h�/ �1 ) L .� �-• Assessors <br /> WELL Location 7 7� (�/�yP�^ Cross Street 7 City ��' Zip 9VO3 Parcel#//� lM 2�l~ <br /> PROPERTY ,t,. �^ <br /> Owner!/ Addres&?1",Z 11 C 4®1,f City6:-C Zi/p 7 4r1 hone# ,a� -17e6 <br /> C-57 Contractor /T S/• � L Address,2AP A/. f45r sr ,ciitW-Aa/,/.,edp9�,Lic#�,o��hone# Seas,«����' <br /> Consultant/Sub Cntr(t97�� SG ICw�/ AddresGr�!rtti rP/City�A� Iti Lic# y.��3 Phone# 7p,�•��ic 9J <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 /> AOIL BORING# a OVER-BORE. DIAMETER <br /> 0 WELL# 0 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 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS��TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAN-Su IA f- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE�PUSH POINT(GP or CPT)GROUT SEAL PUMPED: o Yes ANo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )*OIL BORING a HAND AUGER GROUT SPECIFICATIONS ~77 <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH /S a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /y0 (if YES,list specifications in comment section) <br /> COMMENTS: SCe QTmG�X01 � Q'�..,/�L /J�Q +� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rule and Regulatio s,and all applicable CaliforniaA-0-s-. <br /> State Laws.. <br /> Signed x I �/ / Title/Company f/"rS. 6406,rV4 fP ��!lJ <br /> Print Name �( r Date <br /> (/ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /Tb� �.✓- w'-u^-�� <br /> WORK PLAN DATED: •S" n D'-I" <br /> Application Accepted By Date Issued Cy 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# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> r` �'?1 l��- I SR# S722_3 <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 />