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San Joaquin County <br />Vic;, Eir;E�si_J, <br />Envie onmental Health Department MAP, 14 2008 SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgciv.cirg/ ff HEAi IT IV <br />'r <br />Well Permit Application PERNIH <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 />ub\it <br />F Assessors <br />4L P <br />WELL Location 1 C7 � '\�'r" 1'9 Cross Street omP�^ City f`� r Zip���� Parcel# One' f S ive�F <br />PROPERTY <br />j l A iiinx i' <br />OwnerV C�c , t""�^.,� - ct� • c its Address �nw 'f[Y.IN Cv-•Items D,; , City �vtfl�c� ? Zip 4 S,'Tio Phone# qZC0F ei+4t� t{ H (7 <br />C-57 Contractork1k n'�'4ar� 9-4i.� Address ��= Z;0 -GL ijow City Zip Lic# I Phone# 3� �t t'0'a-t <br />Consultant/ Sub CntrS•Cl,.w -I"a ���ddresse-zic,'4,kv.m,,Q :t h i+�. City L4P-i!- Lic# -1 1%0-141 Phone# <br />GIS Coordinates: X Y <br />Township Range Section <br />FAC# o� <br />WORK TO BE PERFORMED: <br />FEE INFO <br />AMOUNT REMITTED <br />r.�NEW WELL/ BORING (CPT, GEOPROBE, <br />HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />DATE PERM UEST # <br />0 SOIL BORING # <br />lif1NELL # <br />0 OVER -BORE. DIAMETER <br />313 <br />0 PRESSURE GROUT <br />�• <br />0 `Other <br />GROUT SPECIFICATIONS <br />r � <br />COMMENTS: A14ko we115 rnw-t c.A <br />nM1w-3 axe on 'Dk.o•} to r 001 3 wars ate ' o,K41 o�anpd <br />V ` <br />Lothrop -- <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />N,kMONITORING t9�10LLOW STEM <br />DIA. OF BOREHOLE_ 0MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS akt W �rC-TYPE OF CASING: a STEEL 'ILP -VC [] OTHER: <br />[] VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS [] HOSE <br />[] AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS <br />[] OTHER: 0 OTHER <br />APPROX. BORING DEPTH v&d "BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <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 Regulations, and all applicable California State Laws. <br />Signed x �`�-� Title/Company its' f i -.Anus <br />Print Name 0000 t%l �"VC-4 -- M�fo U'z 19s4.1 AP) <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: i 1 <br />I' <br />Application Accepted By , Date Issued j Q O Area <br />Grout Inspection By %n- Date Final Inspection By Date Q <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: <br />AID# <br />FAC# o� <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERM UEST # <br />INVOICE <br />313 <br />1"',Aq5 <br />;q6 SR#S3�$ <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />END 29-02-001 WEB <br />9/11/2007 <br />SIN <br />