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San Joaquin County <br /> Environmental Health DepartmenSITE <br /> 600 East Main Street, Stockton, CA 95202-302 I �D FF' � F -IGATION <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 ISShi&IR4"J(''��ILi`d C FIF_/�l?H <br /> G r,r, It/!t`Ct <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described: hPWAJpll�&rs made in compliance with San <br /> Joaquin Countv DevPIr n f T:.I- - ' '-- Standards of San Joaquin County Environmental <br /> �Health <br /> (D�epartt\ment. / �A ` '7 <br /> WELL Location 1L U_ SVd Gots..► Cross Street City AIN � SCZip���� Parcel#Assessors <br /> 1 Z 1 <br /> y <br /> PROPERTY Zip"�y <br /> 6� hone#Owner_Vttm4 Ot Ne(MLAddress 05 W� 10 �� City <br /> C-57 Contractor 1 . Address 170 Citty�ip LicJV&L Phone <br /> Consultant/Sub Cntr Addres'Al6vWAIT Vity c# /�/ �✓V1�J UQ��j2,`1t <br /> 2� <br /> �� Phone# <br /> GIS Coordinates:X 21,y (D Y 31 77b Township G C (OJ-fq Range FA of Section <br /> WORK TO BE PERFORMED: <br /> p NEW WILL/BORING PT, OP HYDROPUNCH,HAND-AUGER,OTHER*) ` ,DESTRUCTION (choose type below) <br /> $OIL BORING# RGOUT <br /> VER-BORE. DIAMETER <br /> U WELL# RESSURE GROUT <br /> 0*Other ) SPECIFICATIONS_ <br /> COMMENTS:1-opeo rw NVIKyU _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING a HOLLOW STEM DIA.OF BOREHOLE3.1ZrT7 a MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> a EXTRAC--ION a AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: a STEEL 0 PVC []OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-l.7-- TREMIE TYPE TO BE USED: o AUGERS a HOSE <br /> a AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yesjo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> iSOIL BORING a HAND AUGER GROUT SPECIFICATIONS G�iM�v t <br /> O" THER1ff* 1(o OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or a STOVE PIPE <br /> �LONDUCTOR CASING PROPOSED N (if YES,Ii t spe ific tions in comment section) <br /> COMMENTS: A0 �JN WI L NI�F P4 a"q 1.�V f�Clu — GT �F �M P <br /> ` RW " (r If l , YJUIZtGI�LY�7�l v12 I�D�I�UN YkL�7 �p.tl <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMEN PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that 1 4ave grepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord ances, les d Regulations, and all applicable California State Laws. �— <br /> Pu2uJEG-T ENS\2d�nlMbrl�"Y�2 �c �t-=�r✓tl t SAI <br /> Signed x� Title/Company L <br /> Print Name \ 1V-V,�( 75 t VV a Date 2�� OE-, <br /> ,,, <br /> `- <br /> ,, DEPARTMENT USE ONLY C�2o�Ocl9 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �'}� lG�l�lta.✓-�/ o dw�T/V <br /> WORK PLAN DATED: D <br /> Application Accepted By Date Issued / -e Area 'fore <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 FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAIE PERMIT/SERVICE REQUEST# INVOICE <br /> v r yp sR# <br /> 00 Lq <br /> C-57 WC=WAIVER_ C-57 Letter of Au orizotion to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007Ds f � i� <br />