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orN <br /> ,n�, San Joaquin County ( ,,i. <br /> Envil�rnental Health Departinenl" *4 SITE <br /> 600 East Main Street, Stockton, CA 95202-3 20�'j <br /> � MITIGATION <br /> o- (209)468-3449 Fax: (209)468-3433 Web: www.sjgov o 't UNIT IV <br /> Well Permit Application FILE <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 Location tf�, S(1%0 V)� 1 Q Q (�� L� f Assessors . <br /> Cross Street C��e� <br /> Or, A yi.city i\ �.T� Zip E5 Parcel# 2513X2 <br /> PROPERTY �G�'\1 -7 { <br /> Owner ('Yat {�Izl"Address 31 1 f)toss qyl' IJ( City I '� Zip ��1 � Phone# <br /> C-57 Contractor { 1(�� }� - vVry�t� A d+fess �l ! J/0V1iQf V�11 i(City Ih�n +'�f�Zip 7L c# 1 G) one# <br /> Consultant/Sub Cntr / ` I C :��66 ftk ��` (Address vt Lol"w �1 felt' 1Wc y !"l(i'0) Lic# Phone# 20q- 5 <br /> CC <br /> GIS Coordinates:X 'Y Township_2S Range 6 E Section_ <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEr1 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 11J 1 ''t TYPE OF CASING: ]]STEEL 0 PVC a OTHER: OA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4¢2 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )d SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS f�2(lr C'0 cg 0>��- <br /> 0 OTHER:_S OTHER i I I APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 /> 77 ,. <br /> Signed ) 'WA 1 � Title/Company %lY �'v.J r•y)IG II(' �S 'r WI�`l r I/F <br /> Print Name_ to�,r 4 yj U) d(Gv" Date <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: C0 eL4 tS�Yc�� I 1 �2 n <br /> WORK PLAN DATED: _DP'GAAI xq 12e'f- rf. SCJ o r7 <br /> Application Accepted By V i a,h r i G 1)1.e.LCi r }YZPiG1 Date Issued - S Area t¢ 9 <br /> Grout Inspection ByYf,4vria Ke02ri-nQM Date 3 X1-0 $ Final Inspection By�(ir-+Drja&44tC'4wfxac, Date 3-11-09 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: S + i + r r 00 r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35,61 <br /> dr.aaga ' 383. 00 / 7S �(lYr! 2 l`{-08 sR# �a 53 3 68 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc— <br /> EI D 29-02-001 WEB <br /> 9/1112007 <br />