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�a 44IN, oa � n Joaquin County <br /> Envi mental Health Departmenttj� ECITE <br /> " 600 East Main Street, Stockton, CA 95202-3029 �ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd L 5 2007UNIT IV <br /> �I FORF Well Permit Application <br /> '=N'i'� uAVME[V T HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` �11TVSERVIC�F8 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is n& in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 2 rA� Assessors <br /> WELL LocationCAIZ'i }✓I / a ' CrossStreetWQER City ST"'AlTipq,52tr Parcel00- 7 <br /> eERj2 f6/uV (!n. Co. /f UIF <br /> ow�e3TacK?n/y ?�Er2h(n/R4-ad�(sl �9� V. I?M040✓� city J ''ucrW .ziip`l�°SPhone# 20g-`f�'`7 <br /> C-57 Contractor lae191 AiLo OnK/-`caress Pd QoX 73L city R{O V!o/ZiPfYS7f Lic#'1JO07S Phone#-7&7 3?y-' ?dd <br /> Consultant/Sub CntrPADta J4Jl` Addresslo�� 6h-p��KF/c°f6c; gc/z�µr£"C�'ae Phone# 91445-7-(6a/ <br /> GIS Coordinates:X )7.1° 1-Jr 26l- U,Y 3?°��r (2.?N ,Township "� Range Section 30� <br /> WORK TO BE PERFORMED: <br /> %NEW WELL/ BORING (CP ,GEOPROBE HYDR UNCH, HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> )CSOIL BORING# Y� B OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> D'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING 'HOLLOW STEM DIA.OF BOREHOLE B MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS IV/h TYPE OF CASING: B STEEL U PVC ()OTHER: <br /> 0 VAPOR B MUD ROTARY DEPTH OF GROUT SEAL -rD TREMIE TYPE TO BE USED: B AUGERS B HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes $No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS IIJI&I cl^a.YtfJ�T <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 1 CONDUCTOR CASING PROPOSED N O (if YES,list specifications in comment section) <br /> COMMENTS: .Sf-c a&,' IeA Wa�krls,., <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I haveFnd <br /> red this application and that the work will be done in accordance with San Joaquin <br /> County Ordi a ces, IRegulations, and all applicable California State Laws. <br /> Signed x Title/Company /L c J a c <br /> Print Name '4LR-N Date 9/-4t01 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN DATED:IFILE, ADDRESS: <br /> WORK PLAN <br /> T <br /> Application Accepted By `'moi r 1 - � I Date Issued_0_I�'o Area <br /> Grout Inspection By V Date 10 (7 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 62M0I 5 $B 2K Jnr- /b 7 sR# 5a�v <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 />