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Wan 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 />LWRR4G �fa2Cdh/ , 1�s�y %RAe-;K l�S377 <br />Assessors <br />arcel# rs'� <br />WELL Location _Cross Street City / Zip <br />LA'�✓O /G L <br />PROPERTY 2-0 ,?Oq) —3 6 <br />0 nerX4^1L OAQt�I/ie/ edU^//7Zddress/�10 ffi?2EC/4�Cite-Zip �� hone# <br />Y�✓a <br />4,tL/ O- vif o6ei/i✓- <br />�'/3 ^ 5�C� <br />C-57GontractorWR�®W<C1WjAddressgSOyWex) City Zip Lic# Phone <br />Ei✓vixd�iltE/✓i.9t- jai/Ri C/ft�'9b° 9.1-5- .2 f -,P <br />Consultant/ 9uiTCPfTr'.i�iG/f1 /✓ Address �ill� _City�iLic# Phone <br />GIS Coordinates: X 'Y Township 3 Range 5 Section <br />WORK TO BE PERF }.%- <br />aA�-IAfE ORING CPT, GEO OB_F, HYD UNCH. HAND AUGER, OTHER*) p DESTRUCTION (choose type below) <br />Q SOIL B 0 OVER -BORE. DIAMETER <br />WELL # o PRESSURE GROUT <br />*Other %� ` �� GROUT SPECIFICATIONS J <br />COMMENTS: / � •rd �+'� f 7� / `! ��a C71 -S' _'6��fj ✓oma^ s✓ 'i do�w irj <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />® MONITORING HOLLOW STEM DIA. OF BOREHOLE ® MULTIPLE CASINGS ® MULTI-LEVEL WELL CASING DIA: <br />® EXTRACTION ® IR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />® VAPOR o MUD ROTARY DEPTH OF GROUT SEAL _7 Ig-7-TREMIE TYPE TO BE USED: ® AUGERS a HOS <br />® AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED:Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />OIL BORING HAND AUGER GROUT SPECIFICATIONS Werw CEM��T <br />® OTHER:_a OTHER APPROX. BORING DEPTH `� BO�TED TRAFFIC BOX or a STOVE PIPE <br />G✓ <br />in comment section <br />n, n1,e_r awe 7 e e,^. <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 Ordinances, Rules and Regulatio d all applicable California State Laws. <br />—PAD XdZ/0 XX/6 <br />Sionedx Title/Companys�1'I <br />Print Name Date t9 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued ` l Area <br />Grout Inspection By re Date �/�2�107 Final Inspection By `, 1404��- Date <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS'i /,1 0 % ® ';; <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE <br />S R# <br />C-57_ WC --WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-601 WEB <br />9/11/2007 <br />