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FILE COPy <br /> 1 <br /> Joaquin County <br /> Environmental He6ith Department SITE <br /> a-,.. � �.� <br /> "i.. ;" '`�{ 600 E.Main Street, Stockton,CA 95202-3029 MITIGATION <br /> •- � (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/eh.d.d 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 /> I 1 A .fie ,, Assessors <br /> f WELL Location 1250 /1'lC��i14 1 [•Oros street woad w4 r�i city M UIM Iz`a zip Parcel# <br /> PROPERTY 11j 0 wtsf s++4 r-[4"A Sf <br /> Owner f7iat�atMiS C Address Suer f-C 99 b City Sc�e �SL zip 9 S/13Phane# 4115li� <br /> Lr at,/4iva4Space_ 1707 t-ifHf! L1r.�la..�Q 3f —5 <br /> C-57 Contractor Cis fr uc dotd Address 5u/fG fi City_%tA4 7d5C Zip Llc 915 YU3Phone*f05lg7'q-e46 <br /> L,�Llf,r4,'rao-4Space- t7a"IL•Hit ovJto:o( sf IT9S+Io3 T' <br /> Consultant I Sub Gntr Cis l ruc ff Address 3u;tc �4 �CitY O!Q Lic#ClY Phone# <br /> GIS Coordinates:X Z Y- ZI 1 Township Range Section <br /> WORK TO BE PERFORMED: <br /> 7N <br /> WELL 1 BORING (CPT,GEOPROBE.HYDROFUNCH,HAND-AUGER.OTHER') g DESTRUCTION (choose type below) <br /> p SOIL BORING# o OVER-BORE. DIAMETER <br /> 3 kKWELL#- W - I . !......_ 1 .11 PRESSURE GROUT 1 <br /> 0*Othor GROUT SPECIFICATIONS <br /> COMMENTS: . wM-fi Lu-t46,8 IaA, a►....t'_ J 5�(,�o4.tct r•L <br /> TYPE OF VVELL tNSTALLATJON TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING OLLOW STEM DIA.CJF.0OREHOLE__2:" n MUtttPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:, [ L <br /> 11 EXTRACTION 13 AIR HAMMER/DRNEN CASING THICKNESS 5cb1 b TYPE OF CASING: a STEEL PVC a OTHER: J� <br /> 0 VAPOR MUD ROTARY .,DEPTH OF GROUT SEA �f;�ua��rl <br /> 13 L 20-TTiEMtE TYPE TO BE USED: <br /> (♦AUGERSHOSE <br /> b AIR NMR,=626NP o FsUtR MINY(U`P or 6PT)WUT SEAL AU1i P915: d Yes a No (NOTE:MAXwUM FREE-FALL br=PTH IS 30') <br /> Il SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Rd✓f"1014--d b ptn 'f b <br /> f OTHER: R OTHER APPROIC_BORING DEPTH 30- TED TRAFFIC BOX or 13 STOVEPIPE <br /> C6NbUCT0� CAswd PP6Pogn N D _ (d Yet,fist specfffcalfons in comment sectfonj <br /> COMMENTS: l� 1-n�dVt f 9-rf e-c,4-r_ f-;AAL, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKIIJG HOURS NOTICE REQUIRED FOR INSPECTIONS. l <br /> l here ycerti#y I have pre appiical6on and that the work will be done in accordance with San Joaquin ` <br /> County Ordina ,R le n u ns,and all applicable California State Laws. <br /> Signed X Trtle/Company <br /> Print Name J •� �J r Date <br /> s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S. <br /> WORK PLAN DATED' _. <br /> Application Accepted By Date issued0_aWWA!fMft <br /> Area <br /> Grout Inspection By. Date Finai Inspection "date <br /> Destttrulon Intptyt Utin By q g <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. 'AID# FACIk <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK IF i REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> ad114 <br /> Jib �� g SR# <br /> C-57 WC�-WAIVER^, C-57 Letter of Authorization to sign permit_Encroachme <br /> EHD <br /> 602A4 29-02-00 1 web <br /> FII Ir P117Y JU!� 1 1 2008 <br /> ENVfR;;iu H;�IIT HE47'11 <br />