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San Joaquin County <br /> Environmental Health SITF <br /> 304 East Weber Avenue,3rd Floor Stockton, CA 9 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.6rg ehd <br /> U N I 1 1%` <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISS11 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described)!--TAfr."�W'ffc�liF�H I i�ide in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental'ke'a*lth Department. <br /> Assessors <br /> WELL Location S 7, ry Cross Street Zip' cl'fi 5.0. Parcel* <br /> 'T City ci't, I t� <br /> PROPERTY <br /> Owner It Address LA <br /> City i Zip ji4w Phon <br /> C-57 Contractor ofjf Address 9 <br /> V_ I, City L-Z i pL111 L i c# P h o n e#<<Z- <br /> Consultant/Sub Cntr—Advanced Geo2nvironmental Address R 7 qh;;ur Pr] City Stockton Lic#_L_ED_22_7Phone# (209)467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING <br /> (CPT'GEOPROBE,HYDROPUNCH,HAND-AUGER,.OTHER*) 0 DESTRUCTION (choose type below) <br /> ff SOIL BORING# 7 0 OVER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: 5_�i W car r Z d!,-rEo zcdo r:.. LL�­ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING n HOLLOW STEM DIA.OF BOREHOLE�" a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: a STEEL a PVC a OTHER: - <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL%-- -,5 =L"i- TREMIE TYPE TO BE USED: a AUGERS ,HOSE <br /> a AIR SPARGE/OZONE�USH POINT(GP o<C2!T;GROUT SEAL PUMPED: ,,Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 7-1 ji C -711-- <br /> a OTHER: U OTHER APPROX.BORING DEPTH -73�r t , <br /> a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED r4h& (if YES,list specifications in comment section) <br /> COMMENTS: 94,­AC,,;2 I IQ d_5-T�el 7-'- Q 4,L,r Z, 2 Q -7 <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> x � , PA�a N e L i' <br /> Signed 0 Title/Company <br /> Print Name 4,11,Y719- "J, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: &Z3 c N . W,!!!.-s `F La ii e <br /> WORKPLAN DATED: +-g-j-",6 ej- .2-0 .2-007 o o? <br /> Application Accepted By Agt P4• ,g�,,t Date Issued E coi -07 Area <br /> Grout Inspection By V chtr't me& Date -2 -Final Inspection By Y1CAIErr,, A166614 ate 2//, 10,5 <br /> Destruction Inspection By Date' <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> .4 <br /> 55-00 .2-114 <br /> Of ,001 383. 6b Z6 7// 6� /Z-1g.0- SR11 0,0 ,7 t)g2 9 3 00 <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 />