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San Joaquin County <br /> Environmental Health Department S, ,/; it� SITE <br /> �. 304 East Weber Avenue,3rd Floor, Stockton,CA 9202 <br /> '` JL�'llil`ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/Al$ 1 1 2007 UNIT IV <br /> Well Permit Application ENUfOANIcNT NES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUfB �,- <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This(ppli anon iVICa de in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ssessors <br /> WELL Locational 1 I,)- n ^E . 1����1 � Cross Street _City S+���� Zi. _Parcel# <br /> PROPERTY yz s N. <br /> Owner c .� A�d/d�ress /�El -por4d,0 'City l-0' Zip��Phone# <br /> C-57 Contractor W[>0AkM� 1.1��KY.y ress 0 o i3o\b J K JCit&e��/5J .,/ ziiip��'Lic#Phone#/�?D/�� 7`�- � <br /> Consultant/Sub Cntr ATC, A sSOGI l,'W Address 1 )1� 1.cn�wGlvn City�Lic# Phone#—L G'/`5-7C1 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ErNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> eWELL# 11k 6-- N 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A <br /> g4rONITORING @40LLOW STEM DIA.OF BOREHOLE Y 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 54 yO TYPE OF CASING: 0 STEEL g*GC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL A 35 TREMIE TYPE TO BE USED: g-<UGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 9,6s 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH '5--7 OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N 0 (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 Ordinan es, Ru s Regulations, and all applicable California State Laws. <br /> Signed x �_/ Title/Company <br /> Print Name JO1r1 7w,an ate C I I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I l 1 2_ woy'1r1!6a ... l,Jc�•.. " <br /> WORK PLAN DATED: I\ 01-06 U <br /> p <br /> Application Accepted By Date Issued --dbo . Area <br /> ���� <br /> Grout Inspection By kATA nnnQ�-.,� Date S' L O Final Inspection By�A (,xync.c� Date tol'6/y� <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 /> .6-C,f Aq.00 <br /> SR# <br /> a so 3 S OS US <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 />