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000396 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton,CA 95202-3029 �1� I <br /> .- �' �j�ATION � <br />+ " (209)468-3449 Fax:(209)468-3433 Web:'www.sjgov.org/ehdoc- (jjI-I- IV <br /> Well Permit Application EN t -- <br /> NON-RtFUNDABLE PERMIT EXPIRES I YEAR FROM DATE[SS /�R??�' 1�rf j �� �1l�� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. ThTd' �li'iSa h ihrcompliance with San I <br /> i Joaquin County Development Tule,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Dep�a <br /> WELL Location,9,17oyf�VS'rA1iQL 2?F• Crass Street/ e I0 0j4y oC g-r, ^) �5�'Ob Assessors <br /> City Zlp Parcel#f"17—4$ —OI <br /> it <br /> PROP <br /> Tlzip9Ownerj �- b12 "Vyc5iCPASO � VRQ6 Phone# 7$3-0'70:9 <br /> C-57 ContractorV w 10'r d- G Addrese4l Mx f''To_ City :- P( Zlp!5XTLjc#12 Phone#X69 00 <br /> Consultant ISubCntrC-FVLJN �'-060 W �-YS`14ddmssf7P*MAta" .ST-. City.�SCIOILO^/Lic#?G SOA3 Phone# <br />' GIS Coordinates:X Y Township 7 N Range 6fi __Section ' � <br /> WORK TO BE PEFtFORMED: f <br /> 1111 p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) fi)ESTRUCT40N (choose 9pelow) <br /> i 0 SOIL BORING# OVER-BORE, DIAMETER <br /> 0 WELL# p PRESSURE GROUT <br /> it 0"'Other GR UT SPECIFICATIONS <br /> COMMENTS: ?>g S'TFt0 �cra+�e; sr�,� V1�� lw AgVV l n�vy�. ,�J'*.I? <br /> 'TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING i]HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL.CASING DIA. <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> I 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS p HOSE <br />( 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 34') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: d OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have pre ared this application and that the work will be done in accordance with San.Joaquin <br /> County Or/dinces, Rules IfidR ps,and all applicable California State Laws. <br /> Signedx�✓ ���� TitlelCompany F G '3 O?3 f='RQ`'rn'O Farr d$�9Ly'f,T <br /> Print Name 6.6�155r- p y. :� Date lG �, a 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:. <br /> WORK PLAN DATED: 2 bol [ <br /> j <br /> i Application Accepted By W r t cm k a_ L, rA 6 i1dje-f'rLPL-e Date Issued—o"+6 2,0(17 Area 1459 <br /> Grout Inspection By Date Final Inspection By Date <br /> - ..; <br /> Destruction.Inspection By r " ' Date- -g <br /> M COMMENTS 1 CONDITIONS: S M <br /> I � I <br /> ACCOUNTING ONLY: AID# FAC# I <br /> PE CODES FE(;INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 35'02 Gar oa 60..dd ago ` �v'�L SR# D ,5~2 04 <br /> C 5 WC_-WAIVER— C-57 Letter of Authorization to sign permit'___.`Encroachment doc� <br /> I EHD29-02-001 WEB <br /> f 9/11/2007 <br /> k � <br />