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U <br />4. _I <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 />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 />'41 !./i9 dER°C y At,> F�l1y®� G/�✓D�i✓ %�s�2.5'� Assessors <br />o %3 � 2, <br />WELL Location T Cross Street City Zip Parcel# <br />PROPERTfY�/1P2Eci�✓it r 95�� <br />Owner ..fa,i � a � Address City S/mak ior✓ Zip hone# <br />E'9/ v3� 31- lPNFc C/�e 7/ 7 S710 <br />C-57 Contractor�lT Address City Zi Lic# Phone# % <br />R!G L- -A-1 <br />Consultant / Sub Cntr Address City Lic# Phone# <br />GIS Coordinates: X , Y , Township Z /V419e/.y Range Section /3 /,� <br />WORK TO BE PERFORMED: <br />%j4NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />® ® SOIL BORING # 0 OVER -BORE. DIAMETER <br />^XWELL# (] PRESSURE GROUT <br />/® <br />_'Other GROUT SPECIFICATION <br />COMMENTS: N�� �r%p /e /'amue ci�� �al /��/"�%�/ !✓e <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING OLLOW STEM DIA. OF BOREHOLE/ ® MULTIPLE CASINGS ® MULTI-LEVEL WELL CASING DIA: <br />® EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC U OTHER: /tom <br />a VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 3'FT TREMIE TYPE TO BE USED: GAUGERS p OSE <br />0 AIR SPARGE/ OZONE ® PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />€ <br />o SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /✓�9 / G��'J�Ni C/�°Ej E~��t/l�� <br />Q OTHER: ® OTHER APPROX. BO G DEPTH / 7®F Q BOLT RAFFIC BOX or Q STOVE PIPE <br />N;/v /` CONDUC�TpO A I PR p if lis speciticatlons to comment section) <br />COMMENTS' �t` c�GIL /�6.��%� O?:- 'q /`� C`�O XGf%c'- <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 Regulations, an all applicable California State Laws. <br />Signed x//ai �a '.7 <br />Title/Company S6iOV1 /7�� 95;V46 //0E&e 7rd2/D li✓Aj/Gr �!/✓ <br />Print Name A"l C�A^L «Ro e- L Date /��,s' a�p7 s J w <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS l CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT I SERVICE REQUEST # <br />INVOICE <br />S R# <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />