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an Joaquin County All ' <br /> J <br /> Environmental Health Department IT <br /> " 600 East Main Street, Stockton, CA 95202-3029 nn (� ITI <br /> (209) 468-3449 Fax: (209) 468-3433 Web: wwwsjgov.org/ehd <br /> W � �� V I�OT IV N <br /> Well Permit Application <br /> SEP 2 8 2007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pp�� pp ���� �� ��� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thk? libl�rimll'li�66dkkc*liance with San <br /> Joaquin County Development Title, Chapter <br /> �9� --,1111115.3( pand the Standards of (San Joaquin County Environmental Hea A(MR/ yRVICFS <br /> WELL Location � O ` 7 V" LS� 1�y�1' � r"� mycross Street I V U C4T L �'i+lh `15U6 Assessors I UL)- 30 � L[ 0 <br /> City Zip Parcel# 7 t, <br /> PROPERTY �� f• �J p ( I. (r t (aC � l q � (� �C L c�e3 <br /> Owner N CC, �� `` fit' � �` Address t� Box. l5 �.8 City �Zip'"t`7f 1 PhoneC# ' c J .JOo <br /> C-57 Contractor � t G �� ,,n llpplt/+iL��r,Addres��sqq,, I ��� i'l i)W� Iwuy-7�� pCityY� I, � Zip "15S .Aic# � 05�.Ci�hone#_ ?i� 3 -�S'b t) <br /> ConsultantlSub Cntr ? /�V aNtr• l7n.ULY�V< "!{dd7el3sn�3� ShfUN mutt-(t' CityW Lic# � �1�' 7 Phone# �Q67- 1�6 <br /> GIS Coordinates: XY , Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE, DIAMETER <br /> WELL # MW '- t y MW - W MW -t 0 PRESSURE GROUT <br /> 0 *Other GROUT SPECIFICATIONS <br /> COMMENTS : <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t, <br /> MONITORING `(HOLLOW STEM DIA, OF BOREHOLEUIG " 0 MULTIPLE CASINGS 0 MULTI-LEVEL,/� WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS G 'kO p. <br /> TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE p PUSH POINT (GP or CPT) GROUT SEAL PUMPE Yes - (NOTE:tMAXIMUM FREE-FALL DEPTH IS 30•) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION �4ger PFYr 64 <br /> n OTHER:_a OTHER APPROX. BORING DEPTH a�- t Ti" IBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YESh list specifications in comment section) <br /> COMMENTS: a� p,�;�- Q '� $ C't'�eh -F -TD , tW we J-D k ( Q,-F.Cf'W`t rv2 c'vt .t-rE UY <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS- <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O � � s eg�ul`a'-tionts, and all applicable California State Laws. <br /> Signed x Title/Company ^ &\jras <br /> Print Name t/n��c,t�ir Y'iV[ rU11Vt�fLh, L�7,t. � / If <br /> VI.e <br /> Date <br /> DEPAR/TMENT USE ONLY <br /> 'Vow A �GoP <br /> SITE MAP IN UNIT IV FILE, ADDRESS : /DLJ <br /> WORK PLAN DATED : 9W 706 <br /> Application Accepted By / _ .ta Date Issued j�" ? io Area <br /> Grout Inspection B _ rog Date�� '��� Final Inspection By 2 7 D <br /> Destruction Inspection y ate <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 0do 383. 3zzZ C zegoggogg SR# 2d Z <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc N <br /> EHD 29-02-001 WEB <br /> 0114 /9nn7 <br />