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/o \ San Joaquin County <br /> Environmental Health Department 1 �= SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 e MITIGATION <br /> (209)468-3449 Fax: (209) 468-34333) Web: www.sjgcfv ehd UNIT IV <br /> cqK �• <br /> LrFOR� P Well Permit Application lication ERP�/ <br /> ( Ln: <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 /> C/� r.n. ;(•, ((-1;-1. tt"I 1? Assessors <br /> WELL Location <br /> 1_ Cross Street r;,l° S ". 131city Zip Parcel# <br /> C ' T <br /> PROPERTX .) n� it <br /> Owner �:. +:i', "'Y ;, Address ` IV5 NIL,L-i- S i �_ City '' Zip�f�!O Phone# <br /> C-57 Contractor - `�I' AddressL- Rx 5i 11 s") q C �0L"l?z J 'L ' <br /> / City I {1, Zip I f�^i Lic# Phone# C 7-Z.S.5 <br /> c r <br /> Consultant/Sub Cntr �' L; > ;� Address ( I��/I�r ;,y�f/ City�-n Lic# Phone#�fLj� L� f�61� <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BOP.ING CPT,GEOPROBE, HYDROPU NCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> RSOIL BORING# <br /> : f) yl <br /> WELL# 0-k/ OVER-BORE. DIAMETER� <br /> *Other 62-7_31 GPRESSURE GROUT <br /> 635 ROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �! <br /> I MONITORING R"HOLLOW STEM DIA.OF BOREHOLE-6_" -LEVEL MULTIPLE CASINGS 0 MULTI WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br /> 0 VAPOR A MUD ROTARY DEPTH OF GROUT SEAL tQ 35"TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') N <br /> j[SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS r&��-t 0 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH lr✓t.cl✓ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> I CONDU TOR CASING PROPOSED (if YES,list specifications in comme t section) <br /> COMMENTS C) I <br /> C),_„31f11-�I1� ^_t 13-�/'� it /i k I ,L+ '� �W�/ U fY r.'• :)vi: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ,AGREEMENT OR ENCROACHMENT PERMITS'ilop <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 Ordipnces, Rules and Regulations, and all applicable California State Laws. <br /> Signed X L< <br /> Title/Company .• <br /> t_ <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: {'�2`,(/✓� ��-�-t � <br /> WORK PLAN DATED:c��� fit <br /> Application Accepted By /Y 1 L �'�((�, D Date Issued 0 /3 a /15 7' Area y <br /> Grout Inspection By (( �,� VV Date t f'3/r7,:7: Final Inspection By ��( N 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 /> 0 $ 5 85 3 6 t � /0/30/07 S R# — q q <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />