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#F0 <br /> *San Joaquin County 0 _ <br /> Environmental Health Department SITE <br /> 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 /> 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 /> Assessors <br /> WELL Location - MVV>1 }( `' Cross Street l(ot if r City p Parcel# 16 L C }Cc.� <br /> PROPERTY lw�y'r'IL"� tri `1'r9zy 41, - <br /> Owner .31V,/I C�l ?r ,dilClJ- t4,5 Address7CO.1 S City C/irJ'6,v� Zip •IL3/CPhone# <br /> C-57Contractort iC flri�t. ITAddress fS6 Ill�� (TQ City / 9rnN Zip hone# r/zj - .3/� 3SG('.` <br /> r4uay R�.rrr,d( 0r- <br /> Consultant/Sub Cntr (br:r)- , .moi Address i t„'k 2 36 City.Je-a, 0 Lic#__Njj� _Phone# Z-.Z of <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> f1 SOIL BORING# S& L Z 5 br-1 i /3 U/ 0 OVER-BORE. DIAMETER <br /> O;WELL# W'S; NGU-31�At W- 3y, h-IP2 OPRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> "MONITORING gHOLLOW STEM DIA.OF BOREHOLEkE 0 MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA:-4_ ±t-1. <br /> '@c EeXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS .SCti. NU TYPE OF CASING: 0 STEEL , 'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL. 'Z r t TREMIE TYPE TO BE USED: 0 AUGERS IWOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS NL ! Itw.n <br /> 0 OTHER:__0 OTHER APPROX.BORING DEPTH `-�C i h DOOLTED TRAFFIC BOX or $STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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, Rules and Regulations,and all applicable California State Laws. <br /> Signed x;:1 Vyu,yl I'7-g id' Title/Company 1,}Z!4 -, t,1DVr,u'!��� 141 e,'i- k�JJee <br /> Print Name C(t f M/✓l �-G!I I', i. Dale 2 Z b <br /> J DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /5 ' `f W (� Z �'G ) �t w' <br /> WORK PLAN DATED: ^ ” lu a/r1 <br /> Application Accepted By ,y_ L'>r✓'"t.(\ , Date Issued ;1'JJ-i'to%Ci. Area ^� <br /> Grout Inspection By�-6�-^-� _Dare_ y z:� I _ Final Inspection By / Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST 1t INVOICE <br /> SR# L�L,,� L/ -7C. ,r <br /> C-57_ WC -WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />