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UI Joa uinoun'CFILE COP Y <br /> ,a. o` n q tY <br /> Environmental Health Department ,SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202vvn <br /> L • ' (209)468-3449 Fax:(209)468-3433 Web: wwsMITIGATION <br /> Rajgov.org/ehd�.. � 2007 UNIT IV <br /> Well Permit Application <br /> u`JVi' <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 afpplication is 1made in compliance with San <br /> Joaquin County Development Title,Chapter <br /> 9-1115.3 and the Standards of San Joaquin <br /> /County Environmental Health Department. <br /> WELL Location/79ro �E� /Yi(2i/� Cross Street// ECJ{ �" TTSG Assessors <br /> ✓i j77 <br /> PROPERTY r/ �l ,c/ <br /> Owner // cy Address�79J-0 //s c: /l��q� 0ity <br /> r�� Zip J,j77Phone#n,eE - /�00 <br /> C-57 Contractore/ ���. o AddressA9&1- Cyd 7' n r <br /> L cityZip JZY Lic# d0 O'Pho_nee# M0 777-'�/(l0 <br /> Consultant/Sub CnV/�Plene�f Address��-L City it-..c � Lic# PhonerC `���.ZY.��•ZrO� <br /> GIS Coordinates:7Frrrr 6N6. ,Township tL. Ran e <br /> 9 y� Section �y <br /> WORK TO BE PERFORMED: <br /> )'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") n DESTRUCTION (choose type below) <br /> MSOIL BORING# \ 0 OVER-BORE. DIAMETER <br /> WELL# �1��) O PRESSURE GROUT <br /> I U other TJ GROUT SPECIFICATIONS— <br /> COMMENTS:- <br /> TYPE <br /> PECIFICATIONSCOMMENTS:TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> .MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: �- <br /> 0 EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS-R, Z/O TYPE OF CASING: 0 STEEL PVC n OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL%B42 TREMIE TYPE TO BE USED: 0 AUGERS n HOSE <br /> n AIR SPARGFJ OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes n No (NOTE: MAXIMUM/FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS CGMcnY <br /> -- ---- _.. _ __. <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH fQ - Ira 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 annliratinn .A{6 ..0..•••• _r-.. <br /> rill be done in accordance with San Joaquin <br /> County Ordinal Ces, R aState <br /> `Laws. <br /> / <br /> Signedx G!/ � �. L.W, ,/G.^/.c[.,7 L�/'� /-r.��../ L'�✓G 4. <br /> Print Name P _ Dale -z- <br /> ILY <br /> SITE MAP IN UNIT IVF /C�yvr2pt <br /> WORK PLAN DATED:_ f/ . / ) <br /> Application Accepted By 1, (ti�'C iitp—/ I �^/Q/( "d — Area <br /> Grout Inspection 13Y / / / on By "' to 7 <br /> Destruction Inspection By. <br /> COMMENTS/CONDITIONS: ,- <br /> &�'t �` <br /> ACCOUNTING ONLY: .n �, . .cam I <br /> PE CODES FEEINFO -Lliv " "" `' y— PERMIT!SERVICE REQUEST# INVOICE <br /> SR# 5o g <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc7V <br /> EHD 29-02-001 <br /> 6/22/04 <br />