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r <br /> pa ••�r. Van Joaquin County or �111�n <br /> ,�• �Q 1111' _ <br /> Environmental Health Department SITE <br /> ' 600 East Main Street, Stockton, CA 95202-3029 MAR 2 6 ZUTIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd L1�t <br /> P ENVIRONMENT �IEAHMIT 111 <br /> Well Permit Application PERMITlSER <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 /> C Assessors <br /> WELL Location 2-195 �14t% kV b 6Vt �ross Street 5• City 0%A Zip 1/20 Parcel# 16R-0%6-_!25 <br /> PR KIRW"111 'A�wz A j Zaui q <br /> i <br /> Owner (x440ArR'e-17 Address Zq44tp Q�e9t OaM- f, City � Zip g0hone#Uf5q --O 1 <br /> C-57 Contractork t ka-6 kW-4ddrettss 3�W4 414 r-� G� City. Zip ic#V�'5�wPhone# <br /> Consultant! YL1✓1Act Cil Address�WlLt�[��W{9YCity rc� `ue# Phon 11a zfl-Z,-A <br /> GIS Coordinates:X Y Township [ lam, Range (A E Section Z� <br /> WORK TO BE PERFORMED: 1•I tN'S <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") YgESTRUCTION (choose typ below) <br /> Q SAIL BORING# <br /> OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> p`Other GROUT SPECIFICATIONS <br /> COMMENTS: JAW-u WciAfin, T—tr 11$ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a PVC d OTHER: <br /> p VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS a HOSE <br /> a AIR SPARGE!OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER: OTHER APPROX.BORING DEPTH <br /> {]BOLTED TRAFFIC BOX or []STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 /> Countydinancps , les and Regulations,and all applicable California� State Laws. <br /> Signed x Title/Company 1vt0 , T d_1C rIV1yMLI' AQtd-C <br /> Print Name �r Date��2-;-� j <br /> DEPARTMENT USE ONLY �— <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued - O Area 3 l <br /> Grout Inspection By Date Final,fnspection By �r�.�°wl Date =y <br /> Destruction Inspection By Date [%6L <br /> COMMENTS/CONDITIONS: 4 <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> -,sire-x- t,v.� <br /> a,OCP t 5`�r2�? '�`1GI: S R#~7 oS 2 <br /> C-57 W WAIVi_i2� C-57 Letter of Authorization to sign perrnitZ encroachment doc <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br /> t <br /> t <br />