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F70 7• (iol <br /> �0 4"•I".oo `aan Joaquin County L� <br /> x Environmental Health Department '; SITE <br /> " 600 East Main Street, Stockton, CA 95202-3029,E ' MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov or&1e 0 UNIT IV <br /> " /r.,0 Well Permit Application <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 Jo quin County Environmental Health Department. • / <br /> r'Zl�e � '�-���w� r' ,f�_,,,, �n' `C G Assessors /V <br /> WELL Location I j . ZQ I/�4 C Cross Street Citycj�`•JCIC'I�n Zip"I UZI Parcel# _a�.�:... o .IR <br /> PROPERTY Ca( / �'T_Picy�ICWO <br /> Owner 33ye ro Address I 10 Pk2cj� City `5• C '(-d-�.Zip Phone# <br /> 9 y <br /> C-57 Contractor - Address js jjkcity Zip�Lic#ZL/=Phone# ZM—e1 4j:'13 qj <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') B DESTRUCTION (choose type below) <br /> []SOIL BORING# B OVER-BORE. DIAMETER <br /> []WELL# 0 PRESSURE GROUT <br /> []*Others 1 t ` GROUT SPECIFICATIONS t..l a4L4 '0jnVW4 * <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING []HOLLOW STEM DIA.OF BOREHOLE rJ 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: Z _ <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS,, TYPEOFCASING: []STEEL XPVC BOTHER: <br /> []VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS B HOSE <br /> B AIR SPARGE/OZONE B PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING []HAND AUGER GROUT SPECIFICATIONS :�: cr,"-LB� <br /> nF1OTHER: n TITHER '1� APPROX.BORING DEPTH i B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> ✓` I u `rvl"211 ,, /� �✓10"./ CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: I'r-���'t•'� ""t•� r r -7-- -- ��;.-' T�'�—� '7 ✓. � '�=D ���iL <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 Ord- ances, R d Regulations, and all applicable California State Laws. <br /> Signedx � "`��' Title/Company)�1, 1'���✓l, <br /> Print Name '' iiQ iv.. -, ✓ +Dr//'� nT t/t Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: l 5 S� W• �r�l v� y��(� -2a>1 <br /> WORK PLAN DATED: W11&l0—*�- <br /> Application Accepted By I Date Issued VD O 0-1- Area 3G L [ <br /> Grout Inspection ByDate l� �6 Final Inspection By Date <br /> Destruction Inspection By Dae / <br /> COMMENTS/CONDITIONS: a cR.� S e-Y�CUtn��G.r Oft u1. L I 2 I` tlr e.d <br /> � ItZd Lf of <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ZAG.1 BCU' $ 9. �� �3 `,S to so o SR# ooS244'� <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />