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FILE COPY <br /> man Joaquin County <br /> ` Environmental Health Department SITE <br /> 4 <br /> 600 East Street, Stockton, CA 95202-3029 <br /> t MSSMITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV I -�►" <br /> "`�`� Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED b S <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> � ITE <br /> WE•tt Location�S 9 9-iA u,) S1'-t Cross Street LC 9-Aa City, C E(2Zip Parcel#Assessors <br /> �d i 11 <br /> PROPERTY O— 1 to 1 <br /> Owner Ct TY r� ST 0 C kTanl Address 405 &1 E-209-41>0 City STOC JOA/Zip Phone4�1�3w e�l s J <br /> C0.k cptG*r�.(m� <br /> C-57 Contractor�F�C'C-/�V0 Irl Address 23 5 ►�lC-I��1 Nl Citys�OGC Zip Lic# 363hone 20q ��Z <br /> Consultant/Sub CntrL-/1j�p00/AT?-I x -i 1 Address 12�1 C. A"OACcity Lic# Phone# SSCI 2 � -2'�:js <br /> GIS Coordinates:X �'/. (� Y ���1 • Township Range Section <br /> FO�MEE <br /> EW W B (CPT,GEOPROBE.HYDROPUNCH,HAND-AUG ,OTHER• p DESTRUCTION (choose type below) <br /> ❑ SOIL BOR _ 0 OVER-BORE. DIAMETER <br /> /}`'C4,VELL# 0 PRESSURE GROUT <br /> 0 <br /> *Other ol ' <br /> /-1 GROUT SPECIFICATIONS <br /> COMMENTS.Com/ f ErIC-e-OCf{M6A: 7- <% k-Ag r7- Z1< �/6/3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r� <br /> X ONITORING �,O.L�L <br /> OW STEM DIA.OF BOREHOLE Il <br /> ,� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ____ <br /> 0 EXTRACTION 0 AMMER/DRIVEN CASING THICKNESSSC k 40 TYPE OF CASING: 0 STEEL J<VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL$CC, cable. TREMIE TYPE TO BE USED KUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED. 0 Yes �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /V eafi cp-nje-ri +- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH jCe T LTED TRAFFIC BOX or 0 STOVE PIPE <br /> C,,O�N_DU'CTO! CAST PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �P �/�� 1 �G�1IG -!1� � !�l (� f J PS <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 Ordinanc , Rule d Regulations, and all applicable California State Laws. <br /> Signed x_ / Title/Company P(WC f r--,a--,a �J L �7 EC L-0 6(5 T M4—JP-4x <br /> Print Name / �f g.� Y• (j�e Date 1 (4— <br /> DEPARTMENT USE O LY L9.10 D <br /> SITE MAP IN UNIT IV FILE, ADDRESS: N. ��W <br /> WORK PLAN DATED: Q <br /> Application Accepted By Date Issued ` Area <br /> Grout Inspection ByDate 9 r Q Final Inspection By. _ '° — � to 7. i <br /> Destruction Inspection By ate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDC K# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> V 1. lq.og SR# p 3 3 <br /> C-57_ WC -WAIVER_ C-57 Letter of Au horization o sign permit_ Encroachment doc 1��3 <br /> 9/11/2007 <br /> 1-:111)29-02-001 WEB <br /> n _ <br />