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C14 •San Joaquin County • <br /> aEnvironmental 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/ehdUNIT 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 De v lopment T'tle,Chapter 9-7,115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 5'T Z'5W 4.f' -d Lr""e C / Assessors <br /> WELL Locatlonkr bo ri Cross Street t� C-r - n-Y city 5o�d,/.Zip Parcel# -u L 03 zo/ <br /> a,Pw��-5fb A;-// � �_K�fS,Ae <br /> PROPER A,4 <br /> / TS�z Phone# <br /> Owner e��d�.sloc�l'r�-� Address P0 ,�cWc zU�'S City 5/2, t/v—Zip <br /> C-57 Contractor �`-` 6^5r�/-. Address q5D City ip9Y5S3 Lic#d yc Phone# f'?s -3/3 FCC,' <br /> Ln re;S .c -Ro�t3 lYY7%.t'i�. <br /> oubCnlr d Address Cit n0 - Lic# Phone# '7C�-g33—z36� <br /> nsuttant/ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CIP.T,GEOPROBE DR PUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> SOIL BORING# / SG-ZSc,.S(S-Z$,SB-2-J DOVER-BORE. DIAMETER <br /> B WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z I 0 MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA:IM <br /> B EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL D TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes oo (N TE: MAXI UM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUTSPE <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH S"o B BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> /J <br /> CONDUCTOR//// ���/� C�-�ASING P////RRRROPOSED /y/J (if YES,list specifications in comment section) <br /> COMMENTS: UOr'r r-''S 1.$ l _F'rUc_1i V ko Li'l' frC.&— e6-PK=;' <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 Title/Company <br /> Print Name Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted y Dale Issued ` 2v U� Area l <br /> Grout Inspection B Date 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/SERVICE REQUEST# INVOICE <br /> X61 <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 />