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San Joaquin County <br />Environmental Health Department ,J: C CI� L`�L� SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehOR _ 7 2008 UNIT IV <br />"FOR" Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pER' %j1T/SERVICES <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 />I Z �I S Assessors <br />WELL Location ►v>r1�v u F Cross Street p,2rt✓ waw/ —City �oti Zip Parcel# (Ji7 2� J0 _ <br />PROPERTY <br />Owner �' H U h ✓1 Address �� �I ( W�1 `��pp City �r�Zip `IS 3 0 4 Phone# <br />C-57 Contractor Wj"'( WH"l r'<<'�y Address y5 J `r &-V4 City P"o > Zip `lq$ 71 Lic# U u 7q Phone# -70 7- 374 -43w <br />t yConsultant/ Sub Cntr EV\V,'"INK9n �Address33)OC-(101moa PkAl(by- CitCavm2rcn Lic# Phone# `l 16- ll) -i` f <br />i <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) jr DESTRUCTION (choose type below) <br />0 SOIL BORING # OVER -BORE. DIAMETER 1 U ,1q <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: IMM :?i3a'Ly�r}�-t,c�.. <br />TYPE OF WELL <br />IN ALLATION TYPE <br />MONITORING <br />HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ----- <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />ncoru nG r_on, ,T cGni S ' TREMIE TYPE TO BE USED' AUGERS n HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: $'Yes <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS V\ -N <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH <br />COMMENTS: <br />0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />fD y�0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASINGROPOSED (if YES, list specifications in comment section) <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 />Count int s, Rules and Regulations, and all applicable California State Laws. I i <br />Signed � �JJ//��JJ Title/Company <br />Print Name �Ila� k,ut ''q Date 3/3 I%0 <br />] DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: b l Z i�ricru`u ti [a a�P <br />WORK PLAN DATED: 3 ZIQ B <br />Application Accepted By Date Issued rr O Area <br />Grout Inspection BDate 44 jL'q(0%– Final Inspection By V Date O� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC#!3 4A::�— ) <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / S VOICE <br />34-07 <br />%C-C,C>0 <br />16o-3-0 <br />y/g/o;K SR# s 3g`fS <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 />