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U " San Joaquin County FIL Cff-Y <br /> Environmental Health Department SITE <br /> w { 600 East Main Street, Stockton, CA 95202-302GATION <br /> ki�� <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.c <br /> E� NIT IV <br /> Well Permit Application V07 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 0 7 2009 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work desert PT <br /> compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environm <br /> �1 1 ssessors <br /> WELL Location 2J5 7 5o U �k 6 I,.✓l,�.Cross Street Pel hl �. City. Zip Parcel# ��5-/53-a1 <br /> PROPE �I <br /> Owner r oft ChAr&n Address City Zip q // Phone# <br /> C-57 Contractor A' yA it v dress 3g(]q P I r VG-,144it Place.- I S(J0? V�835� <br /> /� ; y Zip ic# hone# <br /> Consultant/Sub Cntr(Zdyu (c��V,,'�ee-A k Address 83�S)u i � City Lic#x0227 Phone# Z y(o�- <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> tVEW WELL/ BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> -9<Other � }-„=_ Wc�Q J.2) GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS O <br /> 0 MONITORING 9-IOLLOW STEM DIA.OF BOREHOLE 100 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:_ Ir <br /> _ L�) <br /> XtXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: a STEEL YPVC a OTHER: <br /> a VAPOR o MUD ROTARY DEPTH OF GROUT SEAL "2-5' TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') (J) <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS t'1ce_'� (C-O-—4 <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH �� c >'�OLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: r::j"IL Ce n ~ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 0 <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. 'S <br /> Q <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin S�— <br /> County Ordinances, Rules and Regulationcy, and all applicable California State <br /> /Laws. o <br /> Signed ,` Title/Company G fe � 3- e4C <br /> Print Name ADate <br /> / Z/7r,--'j <br /> - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 205-7 S o u+ E ) <br /> WORK PLAN DATED\: 0r+, tl Pr lI S 2009 r� <br /> Application Accepted By V I G D r I d / '`L t�lA t'l YI �1 Date Issued JJ eL, � /0 Area 14h7 of <br /> Grout Inspection By V 1 Lht-1 zl Af to 441 Date /Z-/ O Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: - roundu)al-er EW <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 SD <br /> 3sa3 3 S y3¢ D 30--/-49 `2�r7,17 l2-/a-09 SR# 005-9 Cl <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EI1D 29-02-001 WEB <br /> 9/11/2007 <br />