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Pay y c • San Joaquin County • <br /> 2•''' °2 Environmental Health Department SITE <br /> W K <br /> 600 E. 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 /> p Assessors <br /> WELL Location /yC^ /f`!8 w' Ni4MMr,K Cross Street'�G1 �( C- City ST KT�Zip 15a0Q Parcel#o7l-/'�7O 26 <br /> PROPER �, Address S°X 6yo oopBRtCKJ 95258' OT as`!-aa(5 <br /> Owner <br /> CAR, <br /> "OWLES Cit11^/ Zip Phon <br /> "l SCff $$$65 fz <br /> 0 <br /> C-57 Contractor 31+rFI!X p� v� _ ))77;Z-3! <br /> 6RoufYD ZZRo /71y-MAnv �• CitkStALON Lic#� ��Z3 Phone/207L3g X7`88$ <br /> Consultant/Sub Cntr Address Y <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> ORK TO BE PERFORMED: <br /> EWLL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) Q DESTRUCTION (choose type below) <br /> SOIL BORING# oZ <br /> DOVER-BORE. DIAMETER <br /> W <br /> 0 WELL# Q PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE2 tt 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS _r TYPE OF CASING: O STEEL 0 PVC E OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL��ll 5S TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE`�PUSH POINT(GP or CPT)GROUT SEAL PUMPED:`yTYes u No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS`_r�loRT cEM.ANT <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH $ Q BOLTED TRAFFIC BOX or 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 Ordinnaancces, Rules a Re lati s and all applicable California State Laws. <br /> Signed x—/ r=_- r/--"IV Title/Company 71G -�r0R3 (S R6UNP ZZIRb ^'U"4yr/s <br /> Print Name 6R i=rc ' 5/'A Hf- Date 6 Q <br /> DEPARTMENT U/S�E� ONLY <br /> SITE MAP IN UNIT IV FILE, DRESS: Ime) w' <br /> WORK PLAN DATED: Lr <br /> Application Accepted By Date Issued 7-1?, 2-007 Area R�7 <br /> Grout Inspection By Date Final Inspection y Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: R <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a90! e Ono 6� SR#oG a <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 622/04 <br />