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U1 oo ,, 'San Joaquin County �.•/ <br /> L Environmental Health Department SITE <br /> EQ00 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 2Q9)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> VftREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is her6H�merle1tId �nV 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 /> I95 5� Sg v% Je. Cross Street 3 Cit -u5 C. lata Zi Assessors <br /> WELL Location J k A �d S� y p 4S 3 ZO Parcel# 2-Z1S'4-26 <br /> PROPERTY <br /> Owner V;G k i Q- A&40k 0 Address P-0. 130;w, Z O b City SS c a l o vn Zip 9 y 2 U Phone# <br /> C-57 Contractor TE(7- Address113SO Ao►.;Qr Cark Place-City GerdoJq Zip9574ZLic# Phone#gIb-853 - Sd10 <br /> (rrovv.b 's-E-b <br /> Consultant/Sub Cntr Ane.lvSiS Address 11114 Mui^ S+. CityECealuh Lic# Phone# 7001- tr3fr-9Fsts'� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ;NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> to gSOIL BORING# S (r' I S(r 10 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2-" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: /VA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 51 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE $PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes patio (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS VLOO- C4-- P% (r-ro" <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 5 1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: So.\ 10 W, 1 atdyaw,Lek R!�r_ Gl• So:S vapor Sc4w.12teS. <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 Ordinances, (2ules and Regulations, and all applicable California State Laws. 1 <br /> Signed x Title/CompanyS FF �Q 0 V °j I'S 7" <br /> Print Name Ja e— V014/7 7 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: t isti S :7-f",(.,a,, — (2--f <br /> WORK PLAN DATED: g_1 IL- % wc-Gla, gyyn.-.� (� � <br /> Application Accepted By Date Issued Are <br /> Grout Inspection By (i17-�n.�,�e,�� Date 2 2 p Final Inspection By av— Date Z 2 <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 /> actoI L%".vc/ 01- -5-qe kf 1ISR# S 3Zo <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 />