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San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />rrzl� F I " — <br />RM <br />SITE <br />APR 16 , :MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.Sigov.org/ehd UNIT IV <br />i�i�,''�;�iDo11i'��Fh11 H_: <br />Well Permit Application PERMIT/SEI?VICt ' <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 />('6aC'9 <br />k1'5 r 1 La Vf }-oc, io h 9S?O� Assessors r�r <br />WELL Location !y. Gsrtp fil!'e, Cross Street O r City SZip Parcel# <br />PROPERT`F q <br />Owner C 1 �O - e Address `I Z- S N • L=,1. fj�,pfacto. City S�[��lC.k�pw Zip qSr� Phone# 2 °� <br />C-57 Contractor"►a S+� Tt� Address 22?A Te,,j S&fyJgJP, Cityir• R#G Zip /1861 Lic#0VI/V Phone#Elo 30 <br />Consultant/ Sub Cntr C%cj("A �e - Address229 IC446r4 44. CityR C-14 Lic#�93 Q Phone# SId -3,17/7 V3 G <br />GIS Coordinates: X / , Y i' , Township --- Range Section I -- <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING PT, GEOPROBE, HYDRO UNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />#,SOIL BORING # S /% aSB'IW T-OV)Z- TErnp01LnV-i 0OVER-BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 `Other GROUT SPECIFICATIONS <br />COMMENTS: G�ovr�tlPWA'fE►z Lrl1ST�4AT�d►`/ <br />ro;l <br />1-14 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION 2ECIFIATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOL Z- MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS. TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA 5 of U TREMIE TYPE TO BE USED: 0 AUGERS 1 I.1AGE CP VC-) <br />0 AIR SPARGE/ OZONE MPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 1 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />V,SOIL BORING 9HAND AUGER GROUT SPECIFICATIONS t4e-&t CSI2n4AX— -�fe-r'A,4-- <br />0 OTHER: 1 OTHER APPROX. BORING DEPTH M". 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) t <br />COMMENTS: <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 Ordinanc-es, Rules and Regulations, and all applicable California State Laws. <br />Signed x � lf�f Title/Company CE 0 <br />Print Name 10�"'.a 1'D G4 Ll Date 4 -11 -ng <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: t xtT /�✓� 5�or F��c <br />WORK PLAN DATED: 41Tj� <br />Application Accepted By Date Issued Ar <br />Grout Inspection BDate Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />ard+ <br />111 8q,ovSR# <br />151.6�s <br />y/z9o� <br />D5 q o3s <br />iso <br />zCt .C'C) <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 />