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• • FILE copy <br /> I <br /> San Joaquin County <br /> _. Environmental Health Department SITE <br /> K 600 East Main Street, Stockton,CA 95202-3029 MITIGATION I <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 t(V� ! !'TtCI^I <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work desuibed. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards <br /> ,g n q n aunty EmIronmental Health Department <br /> WELLLocationX495 -PaGwr- Ai(C cross street -6L0rhL. City �TOCI (pNLp� AQ 7---A,b <br /> y <br /> Z•g <br /> pRGPOwner �fj Qb <br /> Owner�APt4 54'YA Address 6445 ?A�IFIG A�eity5T 04 Zip�ZPhoneS 916 386`{"6 - <br /> C-57ContractorlA. obI!/A't�R111.WfrAddmss016,8ux33(p C 0 S Zip9y5vLic#1td� PhonceZOY-?? V3dD <br /> Consulant/Sub Cph I-F-P-� INC-- Address1900 PONEIC—ST. cid-YVIU 233 non 5l0 652" -$� <br /> �p rZ <br /> GIS Coordinates:X J o•b I� ,Y —12.1.3Z I ,Township Ralge Section f <br /> WORK TO BE PERFORMED: ClIT, p�.. 1�� <br /> ONE LL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) NEST (choose ty beloW)-" FR �)rN <br /> U ORING# U R-BORE. DIAMETER /LNI�E J <br /> B WELL - PRE RE GROUT AND WD j <br /> 0.Other I Ui SP 10 <br /> COMMENTS: % S ht/- 04 -Iac(r SS a-r -00 I -12�2H- �41R Ta� <br /> cv-r - /AN <br /> TY EOF WELL <br /> '"S LL <br /> CONSTRUG ON SPECIFICATIONS - If <br /> NITORING DIA.OF BOREHOLE _,, B MULTIPLE CASINGS OMULTI-LEVEL WELL CASING DIA:6 <br /> Z(TRArmm n AEN CASING THICKNESS 6 ITYPEOFCASING:J�,�/STEEL VC 0OTHER: <br /> B VAPOR 0 MDEPTH OF GROUT SEAL L IAB TREMIETYPE TOBEUS 0AUGERS UHOSE <br /> gAIRSPARGE/OZONE UPCPT)GROUT SEAL PUMPED: UYes aNo (NOTE:MAXIMUM FREE-FALLDEPTH IS 30•)B SOIL BORING U H GROUT SPECIFICATIONSQ OTHER: ROAPPROX.BORING DEPTH G' IBV r n BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,I(st specrhrations in wmmem sectlon) <br /> COMMENM bG!S1TV-4 a?6N OF $ NONtTbhaNG-WELiL S ANIS ! E7CTRgGlTc7ll/ yy�l� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin i <br /> County Ordinances,Rules�In/J RegulatiioJns, ndd all applicable California State Laws. <br /> Signed Ct'L r- J- Ttlelcompany /� <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DRESS: fL7 �.r -7 2611 <br /> 7 <br /> WORK PLAN DATED' � <br /> Application Accepted DY Dale Issued ����6 -0 <br /> Alea ��7a <br /> Grout Inspection By bate Flnal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: i <br /> FACCOUNTING ONLY: AID# FAC# I <br /> j <br /> PECODES FEE INFO AMOUNTREMITTED CHECK# REC'DSY DATE PERMIT/SERVICE REQUEST# INVOICE � <br /> 29oy WD SR# <br /> _ p52Gf9 <br /> C-57 WC -WAIVERC-57 Letter of Authorization to sign ermit_Encroachment doc N - <br /> E1D29-02-001 WEB <br /> 9/1112007 <br />