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01 R its - frPF,.r / z� <br /> San Joaquin Countytill <br /> ...co <br /> <1Environmental Health Department <br /> ( 600 East Main Street, Stockton, CA 9202-3029 <br /> r VTIGATION O <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> \ JAN 2008 UNIT IV /j,W <br /> Well Permit Application � 3 <br /> ENVrR01Vr"v1EN7 HEALT#t&W, �S <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDpER��1TT �RR`/(� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appl/cafib'rt� Q in compliance with San <br /> Joaouin County Development Title,Chapter 9-11115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> —WE-Et Location 9! N• 5q ' !//A/oss ' /� _Cit Street;*/A4 <br /> �,� y � Assessors G ITY <br /> Zip Parcel* <br /> PROPERTY /f� l ITE wct[s ) <br /> Owner G 1 ddress j !�.E LDnR.ADO City Zip Phon #r <br /> C-57 Contractor jVeCc4stoJaSPeAdde s'?-%5 1/A6[AIQM Cityf�-CrK.TU,4Zip Lic#63638'=Phone 709 5-7712- <br /> Consultant/Sub Cnt a&UATQ/X Adddrreess 12819, AetUV/AG City ars-W6 Lic# Phone#, A-44-25 3 5 <br /> GIS Coordinates:X 1. I6 Z 'Y_121-`7I Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-HUGE ,OTHER• 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# Mw-g "MIuV� . 0PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS n <br /> COMMENTS:C'rfY 1°z_ A-0,ncl,e_j ,-,ap +o,- OGS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING $HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSt5 F( 2 _TYPE OF CASING: 0 STEEL XVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL See. Table. TREMIE TYPE TO BE USED: P,,irUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes/81�o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH e. I LTED TRAFFIC BOX or 0 STOVE PIPE <br /> /CONDUCTO CA G P OPOSED (if YES,list specificatio in comment section) <br /> COMMENTS: Et" �a�j/t P /Gl�� it i 1 rl�/a_ we� ( G�� <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, R es and Re ations, and all applicable California State Laws. <br /> Signed x Title/Company !I L C� ST O N4 <br /> Print Name !//Q y, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �9 <br /> WORK PLAN DATED: Q <br /> Application Accepted By I Date Issued Area V <br /> Grout Inspection By a ED <br /> Dat / L/q D�inal Inspection By to <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 I SERVICE REQUEST# INVOICE <br /> 1�dAAA[ Iff', oR rN6 I• •oS SR D 33 t <br /> C-57 Vr WC=WAIVER_ C-57 Letter ; Authorization to sign permit_Encroachment doc 47 <br /> FiIID29-02-001 WEB W <br /> 9/1112007 <br />