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FILE COPY <br /> �4 qD . �Q San Joaquin County <br /> s :a Environmental Health Department SITE <br /> 600 East Main Street, Stockton , CA 95202-3029 Dr r f� BION <br /> (209) 468-3449 Pax: (209) 468-3433 Web : www .sjgov .org/ehd � L `� L� NI f <br /> UNIT IV <br /> Well Permit Application our 3 j zqq� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ^ „vl �U �1� �7-I HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This �NT HEALi H with San <br /> Joaquin County Development Title , Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health �q <br /> WELL Location � � S.�OGJ, C /r7N7 A41LE ZD Cross Street AIV60C io A✓ City S?aCK7o.✓Zip Parcei# rs 6711706 <br /> PROPERTY / ,/ <br /> OwnerG✓ S-7f"� E�]� RalooE.GT/6'Address_1y900 L�. f/Wy/2, City GO D / Zip -c ' Phone# -y499. 7/ <br /> C-57 Contractor/e/eo�N c✓Are2N Address City Zip Lic# Phone# <br /> Consultant / Sub Cntr 14prC, t96C/A7E-S Address .1117 dd 16 i*L.r/ City JVOILeJwA Lic# Phone# r79 ?E2 � <br /> GIS Coordinates: X 3 D . 055 , Y Township Range Section <br /> N&O BE PERFORMED: <br /> WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # n OVER-BORE. DIAMETER <br /> KELL # 0 PRESSURE GROUT <br /> 0 *Other GROUT SPECIFICATIONS <br /> COMMENTS : <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r <br /> ONITORING041-LOW STEM DIA. OF BOREHOLES•49 rr 0 MULTIPLE CASINGS n MULTI-LEVELWELL CASING DIA: <br /> B EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSCH yO S' TYPE OF CASING: n STEEL OVC 0 OTHER: <br /> 0 VAPOR 9 /MUD ROTARY DEPTH OF GROUT SEALq ftl I kB LE TREMIE TYPE TO BE USED: eUGERS n HOSE <br /> n AIR SPARGE/ OZONE n PUSH POINT (GP or CPT) GROUT SEAL PUMPED: O'Yes 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONSPOATLAPL� CEwezrrABoyC "E 7eulTE <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH / S — / 10 ' 0 BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 'IES (if YES, list specifications in comment section) <br /> COMMENTS: SEE eLAPegPLA ^I r4ir JEI7r <br /> rcA4L + toTElA !_ s ✓ 6So,CFACE /NJeSri� ATiaN /�/Y�07d lAD4. �Jrl��/P�d7 <br /> T <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS , <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepa djhis application and that the work will be done in accordance with San Joaquin <br /> County Ordinances les an lations, and all applicable California State Laws . <br /> Signedx — Tifle/Company OifofEtSiO ,.iAL rho Ld Ci / Jy <br /> Print Name /o �/Ai'/✓C—/� Date ola 1 a <br /> DEPARTMENT USE ONLY <br /> L <br /> SITE MAP IN UNIT IV FILE, ADDRESS : jJ <br /> WORK PLAN DATED : / �7n <br /> Application Accepted By Date Issued ' KrY!P ' r4P _Area DV <br /> Grout Inspection By Date Final Inspection Bye---n- <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CO S FEE I FO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 3 3�)* /S/S / 31 SR# y Z <br /> C-57 V WC WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment clot_ <br /> ERD 29-02-001 WEB <br /> 9/11 /2007 <br />