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PqU I <br /> " • San Joaquin County • <br /> Environmental Health De artme C� ° �rI <br /> " X 304 East Weber Avenue, 3rd Floor, Stockton,CA Stockton, GATION <br /> "c p" (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or -A 0 9 1008 UNIT IV <br /> Well Permit Application <br /> 4LlPoi 'N'fiY <br /> ENT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE SS`JIR MIT/SER HEALTH <br /> ���MIT/SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descdbed. 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 /> South HouDurham FerryAssessors <br /> WELL Location 31488 Sv`'Y 33 Cross Street R dCity Tracy Zip 95376 Parcel# <br /> PROPERTYMuriel Jones ✓ 31448 South Hwy 33 <br /> Owner Address CityTracy Zip95376 Phone# <br /> C-57 Contractor RSI Drilling Address 220 N.East Street CityWoodland Zip Lic#802334 Phone# (530)668-2424 <br /> Consultant/Sub Cntr Geological Technics Inc. Address 1101 7th Street CityModesto Lic# N/A Phone# (209)522-4119 <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> )a WELL# SW-101 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: See Workplan dated 09/26/07 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS See Workplan dated 09/26/07 <br /> )GMONITORING )g HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See Workplan dated 09/26/07 <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 Ordi ule Re ulations, and all applicable California State Laws. <br /> Signed x Title/Company Qt.7.1_. I�t u✓YtC <br /> r J <br /> Print Name h -eAj t rt'\ Date / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / E��G�o7 f 1�12>/07 <br /> Application Accepted By 141t,C tlTTavrrJF��b.� Date Issued ZSr Area�5'S J� <br /> Grout Inspection By i/i//6{ Date // 25- -'�Final Inspection By /j/1 Date__7 '/ f//X <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> '354 ` a5X3$3•` 02oYly tvv,r2 9 y < SR# <br /> 34 393 <br /> v / 005�f323 <br /> C-57_ WC=WAIVEk_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />