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DCT-02-2007 16:52 rAMBRIP 1707 935 6649 P.02iO3 <br /> '"JUL vvwyuAAi vVUUL <br /> Envi""nmental Health Department U SITE <br /> 600 East Main Street, Stockton, CA 95202-302.9 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 Sart Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Deye o ment IIhie,C>lappt 1715 3 a the S ndards of San Joaquin County Environmental Health Department. <br /> !�a�s��rkf •3 Y l�'4c:.. �iC> G,ie&.. / Assessors <br /> WELL Location 6 A,� OA ve ►�,,,,,�_ Cross Street f.,4�- ; c� City .` zip Parcel# 2�1^ /70--d� <br /> PROPERTY <br /> Owner Cs_ � �- AddteGS Z �} A$�K �•. A h 7 9 c��( .a�•,'91 Z.!+7.C' <br /> c-57 Contractor ( <br /> d -.>C 4 4, ,or%ve CityA&nL-,t 1p 9-s711rzLic#-y193'Vr Phone# '7 j6-G3Y-SS1Cy <br /> ,c <br /> Consultant/Sub Cntr 4s.,,� t�Qd.diy� A"ddress •.s -J A- City"Lic#. __,Phone# 7 d7 NS_4.3-K? <br /> 5-"k t>- <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED, <br /> (i NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') PSDESTRUCTION (choose type below) <br /> 0 SOIL BORING# H <br /> titi X11] 0 OVER-BORE. DIAMETER <br /> []WELL# VE1 i + ,/ PRESSURE GROUT <br /> p"Other � U U GROUT SPECIFICATIONS P.rf lt. f,v <br /> COMMENTS: I- r 1✓ L4 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 9 HOLLOW STEM DIA_OF BOREHOLE„fQ!�- AVULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS,�,p TYPE OF CASING: U STEEL gPVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL e,. TREMIE TYPE TO BE USED: R AUGERS WHOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Poe {r1-, <br /> p OTHER: - p OTHER APPROX.BORING DEPTH /--*-,4 p BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /V/1 (if YES,list specifications in comment section) <br /> COMMENTS-. r" e"l�5 !��i 1 •y t.;. .,ra aL� f 57-��a a r.Rt .moi-d....-J-- �r� <br /> ��iYSs4rc�q <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS'j <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,Rules and Regulations,and all applicable California State Laws. <br /> Signed x �_ Title/Company 1�e✓s �.4 5per` <br /> Print Name Ori <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 111 FILE,ADDRESS: 34- 1 E . S e tie 0,22c <br /> WORK PLAN DATED: 2b <br /> Application Accepted By� Date issued -5--o Area f T sq <br /> Grout Inspection ByDate Final Inspection By Date <br /> Destruction Inspection By YL4tUl jx Date - <br /> COMMENTS!CONDITIONS: elf m gy-, /n"zle1 _C Q <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3502 G D.00 (O{ d O e2.va4s /0-5-0� SR# <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment docs.-. <br /> EHD 24.02-001 WEB <br />