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ALF-Z41-Z1,11.11 MUN UL: 11 eM UEUNHIKIX UUNSULIRNIS hAX NU bby 264 (431 <br /> P. r. San Joaquin County <br /> 2 . - 5 Environm :i t:al Health Department SITE <br /> ^: a 600.Fa.at Main P^t,Stockton, CA 952023029 MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/elid UNIT IV <br /> 9`I Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllcallon 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. 12-421215 <br /> A.� Assessors I I 'f O q DO 1 <br /> WELL Location 28'0) V. `�,Au <br /> Ar, aoes- Cross Street City�(� p962D Parcel#--iLg-z) 4t <br /> PROPER L�Oq) 125$6a 0 32 <br /> Owner1�oa. (-Address 1313 2+9.7'a�r n l✓u»cL City �r� zip 52d]'Phone# 931-3SS5 r l coq o 13 <br /> �— 63635'f 237- <br /> C-67 Contractor -P4&&4.(B _ Address 10 -CIty&dng±jLZlp9148DjLlc# Phone#SID- 4d+b- Y5�5 <br /> Consultant/SubCntr +Lyin.t-s.44. ___,Address 12P r&viae- Clty. J '+� Lic# Nf� Pnona#559�26N-2535 <br /> GIS Coordinates:X ,Y To nshlpl Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT G OPfiOBE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> aSOILBORING# .3 e- r qt QOVER-BORE, DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> 0-Other GROUT SF ECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS q ULTI-LEVEL WELL CASING DIA:, <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS Af 4& TYPE OF CASING: B STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEALL_TRFMir E TO BF USED: Q AUGERS HOSE <br /> Q AIR SPARGFJ OZONE Q PUSH POINT(GP or OPT)GROUT SEAL PUMPED: Vas Q No (NOTE: M IMUM FREE-FALL DEPTH <br /> SOIL 6CRING Q HAND AUGER GROUT SPECIFICATIONS - < <br /> Q OTHER_ n OTHER.(L APPROX.BORING DEPTH 5 r Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROboil POS— E��_(If YES,list specifications in comment section) <br /> COMMENTS: r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR EN ROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECT ONS. <br /> I hereby certify that I have prepared this application and that the work will be done In 3ccordance with San Joaquin <br /> County OrdinancesRules and Regulations, and all applicable California State Laws. <br /> Signed x ><-Y6Lr� Tltle/Company <br /> Print Name -� Y Date 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE S: -r8ol t. >4*V -P--4- <br /> WORK PLAN DATED: ko'er' <br /> Application Accepted By Date Issued "L(-Lelf, <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: . AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O t 'j•.o7 Pfn v V SRO <br /> C-57_ WC WAIVER_._, C-57 Letter of Authorization to sign permit y<Encroachment clot^ <br /> EM29-02-001 WEB <br /> 9/11/2007 <br />