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UI • <br /> an Joaquin County <br /> Environmental Health Depart ��L � D SITE <br /> �V R <br /> 304 East Weber Avenue, 3rd Floor, Stockton, C <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov, } ( MITIGATION <br /> 9LrFd>r� 6 *b 4 2007 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE`IJIS$fJ�'��Ib^CN7 FIEAf_;u <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Th s 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 OC4.15 d� U e4LSt Cross StreetV, p Assessors <br /> PROPERTY, �City_- eC3 50 Zip SZJ & Parcel# F5 <br /> Lam. <br /> Owner SCa., ©c(y(�,:, �°,,-,'(y AddressIg1C �t--I ! U - <br /> City--"' 1 ZIP IWLiS Phone# ZO�('Wg — 2 0 U <br /> c-sT contractor Si c dtf-m F y//e Address 2-36�_(.(%' <br /> -- I citylto�k nv, Zgs2c5" gv <br /> Consultant/Sg6�trl n...d�/SIO ,.yU *" Lic#�Phone# LC?—d/Jf --b �/Z <br /> Address CZ2�'olsc,,.�. S c;ty�F Lige �--- <br /> GIS Coordinates:X_I�', ZSZt p Phone# `' —z�r <br /> Y 3g. IS z?` ,Township I'( {V Range II E Section�� <br /> WORK TO BE PERFORMED: <br /> - ] NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER' <br /> (� 0 SOIL BORING# ) p DESTRUCTION (choose type below) <br /> J LWELL#V✓t W ( 0 OVER-BORE. DIAMETER <br /> 0*Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 10 MONITORING 'HOLLOW STEM DIA.OF BOREHOLE . r' <br /> E MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Z//_ <br /> O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS3CH LI('7 <br /> 0 VAPOR 0 MUD ROTARY TYPE OF CASING: 0 STEEL (PVC 0 OTHER: <br /> DEPTH OF GROUT SEAL S.S- TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: KYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS t 11, A <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH $C1 <br /> CONDUCTOR CASING PROPOSED A-)C` BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: (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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi nces, les and Regulations,and all applicable California State Laws. <br /> Signed l <br /> [ �/ / Title/Company y/-Cr7 06 1i ,me <br /> Print Name `1� /r'l�'/,.,Qi.rri <br /> j/lv 0� <br /> DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE, AD RESS: �� E. llhr ?�( (� z <br /> WORK PLAN DATED: `7f / (L,- <br /> / <br /> Application Accepted B _ <br /> Grout Inspection By 1fNS Date Issued-21ZL21,67 Areae <br /> 2- !' y <br /> Destruction Inspection By Date 0 Final Inspection B <br /> Date <br /> Date <br /> COMMENTS l CONDITIONS: v�Tl.. � <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C�_qt7( � <br /> 7 SR# <br /> (sq— 1 L�3t5 INS �,�-� 6 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to signpermit—EHD 29-02-001 P Encroachment doc <br /> 6/22104 <br />