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"in Joaquin County <br /> Enviri��` mentaLHealth Department <br /> 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> r (209) 468-3449 Pax: (209) 468-343,3 Web: www.sjgov.org/ehdl`' 'Ht( UNIT IV <br /> cgC✓FoRTVP 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 /> LV:r <br /> /I // I� C� Assessors ` ' <br /> WELL Location oSEMk A�� Cross Street 5.,kI4i1w City rt..-4I Zip 953 P <br /> Parcel# A <br /> PROPERTTY� (r� II / �G;pi�lS 130' <br /> I' Owner l4 t..�i/f14, cc, Address 1001 LJ � �curc;ity /"2�7� Zip 533"1 Phone# <br /> C-57 Contractor l;C r Addressl5b [{a A j City YI4Ci. - Zip9YS53 Lic#AE00-1 Phone# 75-,3(3-5900 <br /> �p <br /> 363` <br /> Consultant/Sub CntZOIC5� =Address SDC/S /4YY4 .Q 1. .%'.�a [Z"K City S aa. Lick Phone# dP ?7-433-2 <br /> i <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> 1.. WORK TO BE PERFORMED: <br /> i U NEW WELL/ BORING (CPT_GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> #JcSOIL BORING# CIV 1 -"3C�>'—y a OVER-BORE. DIAMETER <br /> O WELL# FILE C O P Y °ROUT s ECF CAT ONS <br /> 0.Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_P <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS I/T TYPE OF CASING: 0 STEEL 0 PVC, 0 OT ERS_ <br /> 0 VAPOR 0 MUD ROTARY - DEPTH OF GROUT SEAL^.;.,e U=4 TREMIE TYPE TO BE USED: ,CA �HOSE <br /> 0 AIR SPARGE/OZONE KUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yeso/(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS b(�G.1� <br /> I 0 OTHER:_0 OTHER APPROX.BORING DEPTH O 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /r✓�(if YES,list specifications in comment section) <br /> COMMENTS: <br /> I 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 t ii I pplication and that the work will be done in acc ance with Safi Joaquin <br /> I County Ordinan 71esnd Regulations,and alt applicable CaliforniaState Laws. � �Signed x -f Q\- Title/Company�Print Name I _ �- Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: f I L U IN — JF c <br /> WORK PLAN DATED: Ma x 241 2-QQ2 <br /> Application Accepted By V) C.� ri /YJ__L'_L�1k 7` 5-� - Date Issued � 10� � ZOjJ 7 Area � s9 <br /> LIF <br /> i <br /> Grout Inspection Bye. Fr r/��F ���'d��cL�zi Date `/-%5 -f� `7 Final Inspection By G/{lf'.L.N`� .�'-/%1Cvt7az ate 7/-1�, - 7 <br /> o Destruction Inspection By �t J Date / O <br /> t COMMENTS/CONDITIONS: Adi./gyj� � .Qsi1/V �u--T in '�'�1�' +U f» �L1/tG of vd SP rnr{'� g7Ve ' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 F8,9,0 0 1 59. 0 '-60 46 1y/h'! - sl-o7 'SR# �Q S24(iL <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EI-ID29-02-001 WEB <br /> 9/11/2007 <br />