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t,QuiN • • <br /> ,o c ..Cbz San Joaquin County <br /> y� Environmental Health Department It , SITE <br /> 600 E. Main Street Stockton CA 95202-3029 -- � I ITE <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chd <br /> Ca •:.' •`'�� OCT 2 2007 UNIT iV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 r)r- , �;1�if�rEiV? �1 ,1}LrN <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. T is applfcati I is 1 n �compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and <br /> the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location_G 301 w ���,� c f(flr Cross Street etttN� M1y/f J Assessors <br /> City �7 Zip �� Parcel# 05 s asp w di <br /> PROPERTYIQeJe+�/�� r �p�•! p d <br /> Owner R 5 .S t;!'R1$T Address lb/00 ��i� '�� y � Zip s'?�`� Phone# <br /> C-57 ContractorIF ��-rl�liivl Address_ a3 �Ur'C,CI��t4M 0/- ty JJt/C�it!/, zip�1 l*76 LI Sf? Phono#�� p2 <br /> Consultant I Sub Cntr /�//0•f/�t� efl— Address_�g�S //y( le City c941 M1 Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> IVEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> 1*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> *ONITORING Q HOLLOW STEM DIA.OF BOREHOLE—IJ2 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS 5L '(1) TYPE OF CASING: a STEEL $PVC U OTHER: <br /> 9 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL lb 7 7 TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes Q Nq NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0�yOIL BO ltN 0 HAND AUGER GROUT SPECIFICATIONS T Llifwi -W t <br /> THER: lC7Ahl t?I a OTHER APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX or KSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED o (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING 14OURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina%�Jes,, Rules;and Regulations,and all applicable California State Laws. <br /> Signed x �irL'�t�¢ovi' + ✓� Title/Company <br /> Print Name ,C�/vr[5 k `1 tea n/ � 6 7 <br /> .._ _Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: .I— 8 7 <br /> Application Accepted ByM Date Issued d 0 6 77 Area 3&11 <br /> Grout Inspection By Date__IS? Final Inspection By Date (ol t->✓lo-� <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 /> U � <br /> AV') <br /> r°� 13rs5^ (d to ')� SR# 5 2z Y7 <br /> C-57 WC--WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6122104 <br />