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�pRa�•N.,co 'adan Joaquin County ..w/ <br /> N Environmental Health Departme �((��(jn/J( SITE <br /> _ 600 E. Main Street, Stockton, CA 95202-30 U VV ((J7 VV((�� TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.orgI !f <br /> J 0 8 2010 UNIT IV <br /> c4��F0%� Well Permit Application t <br /> ENJ(RONIVIENT HEALTH <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE!S fWRM1T/SERVjGF3 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11155.33 and the Standards of San Joaquin County Environmental Health Department. O� �r� <br /> 30� ©o'7'h �I } L C 9 S� o3 Assessor r f(_06 <br /> " <br /> WELL Location Cross Street(.�) �i City .7 �� Zip_Parcel#�T <br /> PROPER 0 3np� �� /1vp�h 5��5�Phone# <br /> Owner em a Address vo Y/11 0 City S�(3CLi Zip(� �/ r5 <br /> �4? 5V!6�W ALA City 5�� /'1Zip l�/�Lic#(�0d�Phone# �S707?o0 <br /> C•57 Contracto R !�� Address /1 L, 96M-Y.- <br /> Consultant/ <br /> � <br /> Consultant/Sub Cntr �1 UGfVI( rI�Address �7J? S�Lu� l��' Cit'5�K Lic# ��07��Phone# 96M-Y S <br /> 30 <br /> GIS Coordinates:X 'Y ,Township Range Setylptei <br /> WORK TO BE PERFORMED: <br /> p NEW WALL/BORING (CPT, EOR OBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choow CU Py <br /> ,SOIL BORING# 6197 !h iel Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: a OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROP SED (if YES,list sjecifications in comme t section) <br /> COMMENTS: ���� ti�.� 6d�SSS wl �� �" IS <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 prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan , Rules an egulations, and all applicable California State Laws. , <br /> Signed x 1 Title/Company ham! 1 tkss/y7 4�o OBJ ls� <br /> Print Name (at yl �l)LMGLP1 Date "J- -3 ��0 / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 36 8 S. IE I DO rat d D Si-re-e,+ <br /> WORK PLAN DATED: c�Q7i UG4 Y ti -30 . g6'01 dun <br /> Application Accepted By V /"'+0 t Q M&/ <br /> T lC��f f �Gf Date Issued VU Y16 l �Q Area 4 Sq <br /> Grout Inspection Byyichr;z Date &-2,2-1& Final Inspection By V1r-4pra IS1��rfli�cc, Date 6-2.2 -10 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: S .S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 309.ov 4.34. 00 3 /036 `e/w 411411 0 SR# 0060212— <br /> 3 5'0 SO 3 3-/ <br /> S.Or <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />