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San Joaquin County <br /> Environmental Health Department u�r r�;, SITE <br /> + 600 East Main Street, Stockton, CA 95202-3029 =L MI-T,IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chd r 'UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED;;raY. <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicattonlis rnade'in'compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartmentAssessors <br /> WELL Location l l�r�VS! Cross Street M�h{t�G4'( City510C K ta``� ZIP 5a�� Parcel#>�7 a$ <br /> PROPERT'( f rN�vS'"rT�a�+L Sl`G�( � ±V R � Phone# <br /> Owner � �Address� City ZiP <br /> C-57 Contractor <br /> V w ��t�-1 t^'�, Address a 3a)< TO City 1 A P( Zjp`S s.� Lic#7 Og4`�Phone#3L4——boo <br /> v , x d�c <tLYS, ddress 1-Qq rfArN J`17' City�S� <br /> ConsultantISubCntr�l� _ <br /> GIS Coordinates:X <br /> Y �pwp$hjp !'I'J Range__6_� _Section <br /> WORK TO BE PERFORMED: EST-BORE. I (choose t p below) <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDRO H A ) OVER-BORE. DIAMETER g� <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> 0 WELL# GRTUT SPECIFICATIONS <br /> Q'Other _ <br /> COMMENTS: <br /> � .S�R4Y NIONC i�!'2r•r[y V'IC[-L.�' Al � � i�t''l/� M w3 -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING B HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 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)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 <br /> OTHER:_D OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or d STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,fist 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 Ordina :es, Rules n Re ati s, and all applicable California State Laws. <br /> ��, / TitlelCompany t 'o �. G. oJivd] '�c���S1S <br /> Signed i <br /> Print Name r G r \I S '4 Date r� l <br /> DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: 7- 12 <br /> WORK PLAN DATED: OrC±) etr t aoo7 <br /> Application Accepted By icf n-r e, L. M Date Issued -,Loo Area 1 tet'S g <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By �.f!�-� 7 ^' Date <br /> COMMENTS I CONDITIONS. S - M <br /> LCODES <br /> ONLY: AID# FAC# <br /> EE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT1SERVICEREQUEST# INVOICE <br /> GO, Ob G0. CJD OJ 3/D ` 11 SR# D ,524 04 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />