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pPa�rN San Joaquin Count FILL C <br /> 9 Y <br /> Environmental Hearth Department SITE <br /> W 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 /> q�1FpRN`P <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 /> WEL Lo ation /�0 W,(!l� P / f Assessors <br /> to, a Cross Street City J G J Zip _Parcel#?(�9-Z�D(0 <br /> PROPERTy ` <br /> owner (,•N7ELLU5 M4('Y LL(_Address! �S71 ;�16N_*atVA'V City�dRQ14NG Zip9i�SDf Phone#3/0b/g•Ub%f3 <br /> C-57 Contractor bS i D2 ii L I N� l uZ <br /> h Address 2Z� �•�S��rxi citywWn��zip9S3�Lic#B 334 Phone#6go•tiis•2424 <br /> Consultant/Sub Cntr 5,41 c Atd'drrees W�l}t'g 'dog U1 Cit lW 414 iLi_Lic# Phone# <br /> _31- /�� / ✓�J <br /> GIS Coordinates:X -"5(lY_121 'C 6 rD Township 0 2-S Range G Section .13 <br /> WORK TO BE PERFORMED: <br /> EW WALL/BORING �c �0 ", FjaCDROPUNCH,HAND-AUGER,OTHER-) bESTRUCTION (choose type below) <br /> OIL BORING# S �t� 0 OVER-BORE. DIAMETER <br /> ---- <br /> U WELL# RESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS: 6C-0rKdfir,' &OAIN,_S 77) n 5 � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING []HOLLOW STEM DIA.OF BOREHOLE, []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: NA <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: U STEEL p PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL '`&6 TREMIE TYPE TO BE USED: []AUGERS J9 HOSE <br /> []AIR SPARGE/OZONE IkUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING []HAND AUGER GROUT SPECIFICATIONS EA/T" <br /> OTHER: 601 Mtn OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> u' I CONDUCTOR CASING PROPOSED0 r 0 (if YES,Ust specifications in comment section) <br /> COMMENTS: )egU13- ' I cl Wi L 1 Ayf 'I la F? �VF.LL� • T S N,51i?(-j)Etj Ol% A VeE&c":FIj <br /> �Qc,t2_E_1../ NW !N/ CIkSIIVCj. <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 Ordin nces, R les d Regulations, and all applicable California State Laws. <br /> Signed x r _ Title/Company WfUI`j1MET4YZ(1yA:F&A'.j <br /> Print Name �,`� �t L�J� Date `7 1 0 U <br /> DEPARTMENT USE ONLY CT� Z9 6 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: i <br /> Application Accepted By Date Issued �' S " Ov Area f7 <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 ccs 5.4 REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> JiclO !�$ ` b5�lb SR# <br /> C-57jel WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encr ment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 QQ 0 <br />