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,%WWI N%Wl <br /> SAN JOAQUIN COUNTY <br /> ATE <br /> TION <br /> z ENVIRONMENTAL HEALTH DEPARTMENTC)) <br /> a 600 East Main Street, Stockton, CA 95202-3029 BCF�WO <br /> ATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.orglehd UNIT IV <br /> tJ;,6.4 FEB 0 4 2-OM <br /> WELL PERMIT APPLICATION (VViRONMEIUT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I�" 'MITISERVICES <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 /> '^� � Assessor's <br /> Well Location] 0 J�-� f✓/�/ 11 Cross Street ��� City Zip9 L� Parcel#�75� s <br /> Property `` t <br /> Owner �^ �(/� O�r Address�0a,�q/L�f�Af OAo�rY �i�/Y'. City�L/rw"J�Idl10 zipft Phone# fit.c <br /> C-57 Contractory Address 100 /✓f/G1' ery e"C City �,4/r 4- L i c Phone ��, ^���� <br /> Consultant/Sub Cnt(jEly)0IJBSL s-�V Address 4�7 l/0«��►�►G« /h City rr V Lic# Phone �6� ��f3 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: y <br /> ❑NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-A'JGER,OTHER*) JADESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER / / / GROUT SPECIFICATIONS <br /> COMMENTS: ,1 0P a 6a�dlry+t'we!!�7 4f,. Ol d'E,-A���O W <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Y �y <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE /t ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:�Z <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER t I" <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE O <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE (�(1 <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Q�R ti � '4 H ^/ F' <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Title/Company C0*!5r/,ii"*,7—, dl` s/'P%ClfTd'a� <br /> Print Name S?et/ n Date ZZ O/O <br /> [/ p, DEPARTMENT USE ONLY <br /> �7�C� fn <br /> SITE MAP IN UNIT IV FIL DDRESS: J �..�-C'�-�"�.rRGI. r') <br /> WORK PLAN DATED: / 0 C� <br /> APPLICATION ACCEPT BY DATE ISSUED /© AREA /7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY Q DATE t7 <br /> COMMENTS/CONDITIONS: L-•Gt aI �yITL�Tir'`. SZ C- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 70- &,Cr 6 ? 7 SR#P0 9 <br /> C-5/ WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br /> 5 <br /> 03 V67 P^ '^ <br />