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3an Joaquin County <br /> Environmental 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/ehd UNIT 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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> -0UY ClU fn Assessors <br /> WELL Location �S1?y� �b ih 1Jd)�:1� Cross Street :f City Y t t+ Zip J�L�-( Parcel# l `,, <br /> PROPERTI( _ �y �, C; <br /> Owner l��'tt'1 14'IV'1M:iP Address 2qJ�► kOs,'L � ICC city _Zir)W" Phone# �2( ()(I'10'2�1� I <br /> C-57 Contractor <br /> rtIl � I fel X'11 Ui1 -'I Address(( �J�SC '! f�( Ut'!� ���{Pil�d{city �'''Vlhll'Zip 0_1Lic#� li.i�fPhone# �."���^ � �J <br /> Consultant/Sub Cntr N1(,(,al3.et.1 0"i nuiYrl'!li /1�,kddress ?3_7 �il�0L 6s)(1 City ' ?I� Lic#L��,;_ Phone# (Z(,ri)qu I-1i <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> Z,WELL# HU.)(, HWjj hl Uu a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: IR66,L'11o, Isla ,60_(06 fly 1.�L'<<Q(1"1lti%d CLQ --- <br /> �r� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (� <br /> `,&MONITORING ;a HOLLOW STEM DIA.OF BOREHOLEIyj__-j" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: -� <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 2' TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes SNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') � <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS TUae IN 1 1 Klock we(ki 11l)a�{ _ <br /> a OTHER: a OTHER APPROX.BORING DEPTH ZSF BOLTED TRAFFIC BOX or a STOVE PIPE a- <br /> r CONDUCTOR CASING PROPOSED J�' (if YES,list specifications in comment section) <br /> COMMENTS:' t�7t'PI 1C 1� \ia)iL P!an dri f(/C{ (�1w?(11hc r C 6oF <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 Ordiraat es, ules d Regulations,and all applicable California State Laws. <br /> 03Lr <br /> Signed �� /lam Title/Company VICQ 4�'QSiC1Q1t� /A( YP(3 C)P�1F.nUit'n'f1YY1Pi��c�l,�(IC. <br /> Print Name 'Rjv-' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: it <br /> WORK PLAN DATED:1� <br /> r7 <br /> Application Accepted By y Date Issued �� Area 9 <br /> C <br /> Grout Inspection By �i Date <br /> '5 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# 'S <br /> FAC# II <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMITM&�12V(b 1 " ST# INVOICE <br /> ,litei l — ?Jr i S�fl I . <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroad I e � <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />