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San Joaquin County MAR 2 <br /> Environmental Health Department 0 �61SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 ENVIRUNMEty h ION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www:sjgov.org/ehd PERM11 SERV Tib <br /> c <br /> FaR Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES YEAR FROM DATE ISSUED <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 9-1116.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location � O $r! 6 . FXE'i4o Air Sr Cross street W A7YS City S "04700n/ Zip - SS <br /> zvparcel# !S3- /S' oo$' <br /> PROPERTY <br /> Ownergilt S7oE.f rs•IC/L Address 7045*) to <-YO&f CDcF7'Cily STae1 lv �/ ZIp.E,& 1Phone#_ G/ L. $" .5 <br /> C-67 ContractoqA! C70 ' .bA4fa-14 Address 9SwO A006 X 0" CilyMr}Arm*ZZIp9y._ .7.S'PrL50 <br /> Consultant / Sub Cntr ATG Af.SOGAtES Address /// ? 6o�d PA6r4 A✓. City MoTEr io uc# Phone# 9w79 a.2a. / <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 b"TRUCTION (choose type below) <br /> U SOIL BORING # VER-BORE. DIAMETER_ set <br /> 0 WELL # g PRESSURE GROUT <br /> [I *Other GROUT SPECIFICATIONS A/6LtT CE7M1'1<:nI/` <br /> COMMENTS: Mw / 7 /Ns-0rtoQ 7o Der*rwW o,� (cp / //fs AIPXok. / o ' oycC, .forl > JIV AlG44 ScfEEn) <br /> TYP - F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING 0 HOLLOW STEM DIA. OF BOREHOLE_ g MULTIPLE CASINGS 0 MULTI-LEVELWELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS S-'H VO TYPE OF CASING: 0 STEEL B'PVC G OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUTSEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS � <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH a-BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules an Regulations, and all applicable California State Laws. <br /> Signed tiles / I7/'� Title/Company PXc+fG-s�iJ �✓it"[- <br /> t <br /> Print Name f✓fFr vE4 Dale 3Af/e 'e <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 208 S 7.t lm + Sf- S�Imrt {�L <br /> WORK PLAN DATED : 1012 l o } <br /> Application Accepted By Dale Issued 312 7 ( 04 Area <br /> Grout Inspection By Date Final Inspection By __.Do OF <br /> Destruction Inspection By Dale <br /> COMMENTS / CONDITIONS; <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3p <br /> 35- 0 3 S 6r' ' oo o 3333 IS 3 L��o� SR# 3 6 <br /> � z4 .o <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />