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u I?v <br /> San Joaquin County <br /> -G� Environmental Health Department SITE <br /> ;Zl <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 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 Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 51.7 W<s4-Chi I-C W2±1 Cross Street Llv1LOlA 5{• City 56,khwl Zip 95x06 Parcel# IY77- 6?Y-o40-000 <br /> PROPERTY Cf o, <br /> Owner Dom r7Roc)?&CS. Address M04 05 ci0-- City 56,kt VOI Zip /�� Phone#c2O'?-!f 4S-9 <br /> C-57 Contractor P(e c ioe 5&—plt' _Addresso736S W:SW-, YC. City 56k` -1 zip9S14SLic#(.3LMiPhone*7-6 -L/6S-EFIZ <br /> Consultant/SubCntrSli,"-•-S LnvtCan—Q4ddress Phone# 9 25*-2 885 2o3Z <br /> GIS Coordinates:X 'Y Township w� Range___ Section <br /> WORK TO BE PERFORMED: <br /> `X'NEVV WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# Mw �5,Mw g2,�µ,.,.g��t,tw-roz, �lw-IID/M94-12-0 a PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING HOLLOW STEM DIA.OF BOREHOLE_2 n MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: oZ _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SLIn qO TYPE OF CASING: 0 STEEL kPVC 0 OTHER: <br /> els <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 33-Fa 78 1 TREMIE TYPE TO BE USED: AUGEF $HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: `,(Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS S7. �a w+�er a�+ , 915;% V)i <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH yS' fo 9'a ' ,'BOLTED TRAFFIC BOX or U STOVE PIPE _ <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) Jt <br /> COMMFiTS-Ti�+o 0) ws��S wl�/ )1434'" '�v 9a Lfs <br /> uJ� •1 LtSs.� �f -C.ri-ail e>F '��.t.id �.A¢70 a./..C��s• � � j <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I 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. , n <br /> Siq �"'^"—S a- Yom- Title/Company Slna� c►1J`tOnvvJr,.•7C't�.�f �HC <br /> Print Name c w•.ts A • Date 03//W6g <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S 65 o, <br /> WORK PLAN DATED: It 10-k_ 4ti o / <br /> Application Accepted By /Date Issued 3 (95 Ds�- Area <br /> Grout Inspection By `A-V�..•— Date 3 zi Final Inspection BynA�rCA—, 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 /> 2901 1 87.00 /cwt&-c 0- 3 N jo?' SR# 5 3 6 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 />