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S'�-_, San Joaquin County <br />Environmental Health Department <br />P 46V <br />1 8 East Main Street, Stockton, CA 95202-3029 <br />- (309) � OW -:3 j9 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />'j,:) ,Li I I LI <br />rt1'�iT/S��/!G`S Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 l2a EaJ Mort, Law Cross Street Uu� La -i City a Zip S21 Parcel# 104 1 y o� <br />PROPE TY C <br />Owner oc@K�Il,e1 Address %� �Qroa Ala= City.x,tnnrnewye Zip S'r/f Phone#(V) 7C0'y <br />C-57Contractor C-lAxa,L,'a,at �Address3632 0 --sec C,«je. City?4�,tt,,, (dj#Zip f6%OLic# Phone# 6 78-m <br />Consultant / Sub Cntr 5FCo(2Address3o'7 K.�e�e I, �t,o City�c# Phone# 0/6) S6/- D Y�O <br />GIS Coordinates: <br />,Y <br />Township <br />Range <br />Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL# tV6y-/, /►?14-2 /e7&y 0 PRESSURE GROUT <br />0 *Other —�—� n /��GROUT SPECIFICATIONS` 1 <br />COMMENTS: R_' SFCoa WDrkf&G a/nd"f enH�Mt%ct o� Aied <br />i_2.5� O� <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS /0 <br />PE CODES <br />MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br />REC'D BY <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS L Yrs TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />Qq.oJ <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 3e " TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 N(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS W`MA r <br />n <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH SS BOLTED TRAFFIC BOX or 0 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinanc , Rules and Regulations, and all applicable California State Laws. <br />Signed Title/Company A .4 � 1i` ,l"I 'r �7<e-vn7tatia Lac. <br />Print Name -r/U /v%I'l[r, ham. Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1'r'06 �= <br />WORK PLAN DATED: <br />Application Accepted By Date Issued�Area 3G ✓l <br />Grout Inspection By Date Final Inspection By Date J� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ST # INVOICE <br />3�ot <br />$q.oJ <br />Qq.oJ <br />—�S°l5q'�. <br />�-Lt (A SR# <br />C -57 L/ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit <br />EHD 29-02-001 WEB <br />9/11/2007 <br />