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'D r. <br /> IF <br /> SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT Z0�8 SITE <br /> 600 East Main Street, Stockton, CA 95202P,ROR9r,%1:'1=11,14-111f, MITIGATION <br /> �q N•P Telephone:(209)468-3449 Fax:(209)468-3433 Web:mft% tov14 UNIT IV <br /> WELL PERMIT APPLICATION FILE <br /> COPY <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 /> Well Locatio5-0 n *� �v�c y i Zip (�3/tom AssessoParcel#rZ3�l S-02 <br /> S Cross Street 1,. Cit Tvt,L� <br /> Propertyle-2 �!- <br /> Owner__. �/ Addres % `(�!i/l7��/G, , �""�///f�l City - d Zip 'hone# !/�� <br /> C-57 Contractor Y 1 nn� ��� Address�Z27 G,v!��it//�/ Cit Sc,, C ✓� Zip�Lic#A.5-P.1-7Phon `2 <br /> Consultant/Sub CntrA77l—�� t_T Address(s�i���`��Dv�^PFa/ IN S 1 VL+vtCfiL0 Lic# Phone�/�Jl ��`T z-5pl c/ <br /> GIS Coordinates:X J 1 Y f Z I Z Township ZS Range SE Section 7 S' <br /> W RK TO BE PERFORMED: <br /> NEW WELL(BORING(CPT,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER") AT <br /> DESTRUCTION(CHOOSE TYPE BELOW) <br /> /EjSOIL BORING# G P k Cn PW —� IC <br /> C-1 C.3_ 3 <br /> _3 �3 �—�� ❑OVER-BORE DIAMETER <br /> ❑WELL# 3 G� t S PRESSURE GROUT <br /> [:],'OTHER y� GROUT SPECIFICATIONS <br /> COMMENTS: ►!J � Ale /IC" �,t <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z*EOINo <br /> CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS O;CASING:❑STEEL VC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEALIE TYPE TO BE USED❑AUGERSOHOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)M GROUT SEAL PUMPED: SE:MAXIMUM FREE-FALL DEPTHIS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS V 4 �—�%�nL' iIL-/6-P,4z,�,1"4 <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 2-0 '(�`4 ❑BOLTED 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 certifythat I h Ilve prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an all plicab alnia Laws. <br /> Signed Title/Company <br /> Print Name �� L� S ���cl_. Date -7 ��/d� <br /> DEPARTMENT USE ONLY 29 59 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 4t5 Lb r'r/ p�Y11- <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 Ve WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENC CHMEN,TT DOC <br /> EHD 29-01 11/5/07 IW� Af CCPEflM11'7tPP'�✓ <br />