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SAN JOAQUIN COUNTY VW, <br /> 2 2i ENVIRONMENTAL HEALTH DEPARTMENT <br /> (� `! SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.ara/ehd <br /> 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 /> Well Location�5_�i F - Assessor's <br /> Cross StreethS<,t(l/V�(lI Cit S/�G��%Z1A� cjs�p - <br /> Propert -3-- - y --- -------Ztp � Parcel#_ (t 7 f UU�S <br /> Owner - ALL f 11-. rIGI Address 2-201Co, C�lltll� t 2- <br /> City s 'GID A) Phone Its 4-.-7 <br /> _ - . CityC-57 Contractor p- Address asyL�-k4/-U PL Zip n3 6 �r <br /> Phone� / <br /> ConsultantlSub <br /> Cntr lam( �'j���y5 gddress �� � /}/�t)r`(�Q y Q Cit ,tU ` <br /> _ I_ b Y � C1��� 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-) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# S ❑OVER-BORE DIAMETER <br /> ❑WELL# __- __ <br /> — ---- <br /> -_ _____ PRESSURE GROUT - <br /> ❑*OTHER -- - — -- <br /> GROUT SPECIFICATIONS <br /> COMMENTS: 1�17RlL�V7)j C�VE t�� IlIS f(�`( :i� i2_! y r motif i�1Z71 L �Lt S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MON'TORING ❑HOLLOW STEM DIA.OF BOREHOLE 0f ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:2�it <br /> ❑EXT RAC TION ❑AIR HAMMEFUDRIVEN CASING THICKNESS SC-M 4C)— <br /> C)— TYPE OF CASING:E3STEEL k?f PVC EJOTHER <br /> ElVAPOR ElMUD ROTARY _ DEPTH OF GROUT SEA&4V4K,S tX b�TREMIE TYPE TO BE USED❑AUGERSW HOSE <br /> ❑AIR SPARGErOZONE [--I PUSH POINT(GP OR CPT) GROUT SEAL PUMPED: Yes ❑No (NOTE:MAX-IM`WFREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS\ \ <br /> c t e - <br /> ❑OTHER: OTHER: SaN10G APPROX.BORING DEPTH ' 5d BOLTED <br /> �TRAFFIC BOX OR [3 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if ,TRAFFIC <br /> in comment sectien) <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,andallapplicableeCC I'fornia Laws. �� p <br /> Signed ,�C-�_// �--_--- i Title/Company ��/i�C•��,1"i�1�,- L L.riL�� 1}""�'- <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �,�( < C/ �)�.G �� o��f p L - <br /> opy <br /> WORK PLAN DATED: Id 1-1 o iZ ' <br /> APPLICATION ACCEPTED BY qq -� D , I�^. �� DATE ISSUED [0 4s AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY_( jCa v(�y( DATE 16]1110k <br /> DESTRUCTION INSPECTION BY_ DATE _ <br /> COMMENTS/CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3S`ot 5t9.vo - <br /> X-3 ,tt 79 0c, sb Z,01!5 Uf 6 � o� S R# 5 Z3 I <br /> C-57 i INC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 1115/07 WELL PERMIT APP <br />