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1I . San Joaquin County <br /> a Envir v .tmental Health Departme SITE <br /> 600 East Main Street, Stockton, CA 95202-30 �1)JIITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web : www, sjgov.org/elid UNIT IV <br /> Well Permit Application AUG G 1 2,009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE SSry" <br /> ryUN�I" ��rE[� fj� LT�-1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ` `T/�li �lit��md 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 /> 1 Assessors <br /> WELL Location 20 ffS �, tiA(S aoA) 7 S'7. • Cross Street LAUR C- c- City S_o c K lav zip 9 70S Parcel# / y/- 112 - O.3 <br /> PROPERTY / ' 1 <br /> Owner EAAIG1,CT o/�/�/ pA/o Address S3 / 3 rV . 1GA10A jJ/! . City [. 0 n'u E +� Zip9S13 Phone# `�8�. 70,F3 <br /> 2 AA/CYO <br /> C-57 Contractor C %SCA4DE Address 24& 112 0n6 C/2CL6 City colfb0\ - Zip 9S7 Lic#9Y Phone# 9j:� 61Gr1164 <br />! <br /> Consultant / Sub Cntr 4rC /}9rcrl,};4 .s Address 1117 Lo.JE PA Lv AVgCity_e4�Lic# 9577 Phone# S792Z2 / <br /> GIs Coordinates: X , Y., Township Range Section <br /> WO < TO BE PERFORMED: <br /> gl EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> WS0 IL BORING # 0 OVER-BORE. DIAMETER <br /> NELL # TwO S'PR+� C C.�GLi-c' OPRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING R1461-LOW STEM DIA. OF BOREHOLE - <br /> � {i'n �` 0 MULTIPLE CASINGS ,y'mULTI-LEVEL WELL CASING DIA: � <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCh/ $ o TYPE OF CASING: 0 STEEL U-15VC p OTHER: <br /> W0 V FOR 0 MUD ROTARY DEPTH OF GROUT SEAL !SSI TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> IR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS/)E/J-7— (✓t `VI E /yT <br /> 6 OTHER: 0 OTHER APPROX. BORING DEPTH cT0 r D,96 TED TRAFFIC. BOX or Q CTO\/E PIPE <br /> CONDUCTOR CASING PRg/POSED i a v (if YES, list specifications in comment section) <br /> COMMENTS: SEC^ fETG'S /9 Zo rJ - Plc. d ? TG-STiN cJ o.CK F'c .N✓ 'fl /}%C—A Q&r�O cI <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 prepare this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc s ules n gulations , and all applicable California State Laws. <br /> Signed �� Title/Company g� eaC cOc. /1T .1-9G /95soci .(>C-5 <br /> Print Name /m .S-/� L-� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED :, i 2 t Io ri <br /> Application Accepted By GLIA ,,,,. ru � Date Issued Fr / z 1 Dl Area <br /> Grout Inspection By Date Final Inspection By i��_ Date, ) 11 DI ei <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3S0 `! `{ 3 . 00 os"Ize2 (, F fs Z1 /e9 SR# 00 ,5 � <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permitL/ Encroachment doc <br /> EHD 29-02-001 WEB <br /> 9/11 /2007 <br />