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0 • <br />San 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 />�` . �R 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 gDepartment. [� �/ <br />/I/ 0 yF-,�C y �D �ty»D.�D ,u,41p,e / �ZS'� AssessorsQ /3 �TOZI 2r <br />WELL Location Cross Street i City Zip Parcel# <br />PROPERTY <br />R^f�jA2EC % S%3x66OwnnerSAddress yO�p Pne <br />G �t /vAddress 36 33— �t�C C/,e ;9fWe� e*e De -14 7/ 7 S'/O 10W — 6 X00 /d 41 9 <br />C-57 Contractor City Zip Lic# Phone# <br />R/G t eA1 <br />Consultant / Sub Cntr Address City Lic# Phone# <br />2 /!/dR/ % ��9j1 <br />GIS Coordinates: X , Y ,Township y Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") B DESTRUCTION (choose type below) <br />SOIL BORING # n _ 0 OVER -BORE. DIAMETER <br />*Other <br />O <br />WELL f. _ 0 PRESSURE GROUT <br />/� / GROUT SPECIFICATION <br />COMMENTS: /�C� %�'�j� /e 10': 5 e C j�d? /1� � "��;/ %✓ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE�� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: -� <br />B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS _TYIPE OF CASING: B STEEL B PVC 0 OTHER: —/✓ RR ' <br />B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL -6'F7 '*O`` TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />B AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: B Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 3_0') _ <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS IV64-7 <br />45-1"6AI7, e6711,leAC6E�✓�(1h///� <br />0 OTHER:_B OTHER APPROX. BOp2q DEPTH _ 0 BOLT JRAFFIC BOX or 0 STOVE PIPE <br />N; /Z✓ CONDUCTOr(9ATSIWP kif��isrspecifications in comment section) <br />COMMENTS: leE /f— '8017- rlm 0'r- i�/p �E — �O 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, Rule d Regulations, an all applicable California State Laws. <br />Signed X.'; / �iie t�(/� i /ia o_7 Title/Company S€�/�Z X�� <br />Print Name / �/ « ^�'7���,ex0e- L Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Nov 15 2007 <br />Application Accepted By w Date Issued AIr/sERVIC�S <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />REC'D BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE <br />'w <br />�y <br />SR# f%52*© <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />