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Ur FELE COPY <br /> ,o co can Joaquin County U <br /> z Environmental Health Department tcnV, ITE <br /> 600 East Main Street, Stockton, CA 95202-3029 �� " . +VIbATION <br /> ��� <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ d / <br /> o .P �rY,� ��p�UNIT IV <br /> FORA Well Permit Application Pyr, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I l T/`SCRV//C' <br /> Application is hereby made to San Joaquin County for 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 arX the Standards of San Joaquin County Environmental Health Department. <br /> �/ 17 Assessors <br /> WELL Location `� �7W11 fv,- Cross Street E-1 de,- City S f2�h Zip Parcel# <br /> PROPERTY ( �J �/ /_/ <br /> Owner C r" of S�dc 2�ti Address X05 h � vl� o City �/1+o/G1�n Zip�s�-Phone# C -a'l) �s%'�'�N�( <br /> C-57 Contractor SDr6� rk� m-,Address X365 I✓, w---tn j/,�! City Soak" Zip*14Z'P-L Lic# dxcY Phone# 62-01) <br /> Consultant/Sub Cntr d o,-- ,, ., Co.,.,,jt, .k Address 12-YJ <br /> City �/is v+v Lic# Phone# LSS 1�3 z 1S i5 <br /> GIS Coordinates:X 3'T (V I Y-1211-,2-J- 0 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> fVF„)gl WELL/BORING (CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> I SOIL BnRwr. �/I p OVER-BORE. DIAMETER <br /> p PRESSURE GROUT <br /> p`Other GROUT SPECIFICATIONS <br /> COMMENTS _ <br /> U <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 'HOLLOW STEM DIA.OF BOREHOLE (0'/ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AF DRIVEN CASING THICKNESS .�f� TYPE OF CASING: a STEEL a OTHER: <br /> a VAPOR MUD ROTARY DEPTH OF GROUT SEAL !L TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> Al OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Irrm e-,A <br /> R: Q OTHER APPROX.BORING DEPTH '15O ,BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /VO (if YES,list specifications in comment section) <br /> COMMENTS: D /LGt. .b w NF`r <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, Rules and Regulations, and all applicable California/State Laws. <br /> Signed x Title/Company �rGom� +^>70 (A✓ita��tvts <br /> Print Name k,,, KAeh Date 10-11-07 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: F /V' Zp-S7 61E13 - 4/57- <br /> WORK <br /> /5TWORK PLAN DATED: VAt07 <br /> Application Accepted By Date Issued l O 7 % Area <br /> Grout Inspection By Date Final Inspection By Date <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 /> 2Ro! E5 _ �' C+ -t� SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroa�clh,ment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />