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San Joaquin County �� }� <br /> Environmental Health Departn�o ( �0 V E D <br /> '? 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.�ha 0 2006 q <br /> Well Permit Application ENVIRONMENTHEALT <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE gt&gIT/SERVICES <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> // // Assessors <br /> WELL Location Z IZO IS/ Do'-.,jo _S1�, cross Street fl�l arti9S City O 1p '7520Yparcel#J 125-2/-OSo <br /> PROPERTY <br /> �� // <br /> Ownerl�6r G"t& Address Z3tu r I. o r� ay 55�c&/ ft_ Zip 4 w hone# Z.y f^ <br /> C-57 Contractor Address 95 <br /> -Q f/e Y6.J City_t ip VJT*Lic#YY5 Phone#9ZS-3/3-.57F'00 <br /> Consultant/Sub CntrTem T..c. AddressZ76✓cIL%% sSf- Clty,,Sc^o�Lic# ' Phone#7o7-9 s_4/F'.YO Iiy <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: I <br /> "EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) II <br /> ,,"EW <br /> 0 SOIL BORING# ()OVER-BORE. DIAMETER <br /> ,WELL# N v /"1 V. a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS . <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 41 <br /> ,XAONITORING 'HOLLOW STEM DIA.OF BOREHOLE 10 []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: y <br /> O EXTRACTION (]AIR HAMMER/DRIVEN CASINGTHICKNESS,SG, 5(9;1 <br /> D r TYPE OF CASING: 0 STEEL XPVC []OTHER: i <br /> a VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL LS- A TREMIE TYPE TO BE USED: )(AUGERS O HOSE <br /> a AIR SPARGE1 OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes jXNo (,NCS"AXIMUM F�2EE-FALL DEPTH IS 30') <br /> n SOIL BORING a HAND AUGER GROUT SPECIFICATIONS �or 7 Ce n e f� <br /> r <br /> a OTHER: p OTHER APPROX.BORING DEPTH YS �X•BOLTED TRAFFIC BOX or ()STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /V (if YES,list,specifications in comment section) <br /> COMMENTS: <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 prep ed this application and that the work will be done in accordance with San Joaquin <br /> CountyOrdinan s[n Rules atnd a ulati ps,and all applicable California State Laws. <br /> Signedxe Title/Company� lS�r� /"tK/K�� �n`�i� <br /> Print Name /� "`-'�"�- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN:DATED: <br /> Application Accepted BA4nV -/ y.ti+^7/�/'� ' Date Issued 10 -5,�� o Area t I <br /> Grout Inspection By - Date 11 111 0 t- Final Inspection By �.....AL/.++�t.I. Date Le <br /> Destruction Inspection By Date T - <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 'SSB( Yf.oC, $C(,.C, C> 2v3g3 to�s�'L SR# pot{$ �S} <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br /> r . <br /> I <br />