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San Joaquin County IL�j _ ';' <br /> ll� , <br /> z � y Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 200MITIGATION <br /> "i (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehdINIT IV <br /> Well Permit Application P ,�'111-I/s F R iii <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 /> ��� a �aC.>'(.[. l� n4CAQTHNrr�"� a Assessors 2 2 <br /> WELL Location oss Street ""C ity Zip r15*37� Parcel# SD- 70 -09 <br /> PROPERTY' <br /> Owner ( G tit Address/- - - CityZip-hone# zo9 `j`t z-/S7o <br /> C-57 Contractor I^)ond.,-rd Dti,III- I Address SSD 91'1'.r ao4-p City to VISTA Zip N571 Lic#-71U079 Phone#�07 37y- yioo <br /> Consultant/Sub Cntr rf'rsotJ5 Address /00 W. W-IN ST. City­JA w Lic# Phone# L&7- L/yo-6047 <br /> GIS Coordinates:X 'f- O Y���- ��7 Township Z SOk Range 5 6-,s-r Section 7 � <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# A 3-Z o OVER-BORE. DIAMETER <br /> JK WELL# W-•S 0 PRESSURE GROUT <br /> *Other <4 49 1 GROUT SPECIFICATIONS <br /> COMM NTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `AMONITORING6) []HOLLOW STEM DIA.OF BOREHOLE 12 []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 51-k•C40 TYPE OF CASING: p STEEL )'PVC []OTHER: <br /> 'g VAPOR ((S) []MUD ROTARY DEPTH OF GROUT SEAL 0-3 -9+ TREMIE TYPE TO BE USED: ,AUGERS []HOSE <br /> []AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING([3) 0 HAND AUGER GROUT SPECIFICATIONS CA+,t p S <br /> []OTHER:_0 OTHER APPROX.BORING DEPTH Z(-44• BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> c^ _ CONDUCTOR CASING PROPOSED /J (if YES,list specifications in comment section) <br /> COMMENTS: S•�-�.. ATTA'-'+&D-& 1.J. -tj C'o n (�{�o J Di h'1/L4, <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. <br /> Signed x Title/Company f 1(L l,j<<r'l Geoi. r 5 T- Z)P', f-jS� S <br /> Print Name -TFf B L, r,d 6- Date <br /> DEPARTMENT USE ONLY 4 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: (:OL <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued ( ��d Area <br /> Grout Inspection By Date Final Inspection By 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 /> L?'fo '706 YZ61 �=15= 05 11 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />