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oPQU rM c 1061an Joaquin County I -, <br /> FILE COPY <br /> ). O i' D 1 n <br /> r % Environmental Health Department � I�/� I;�ITE <br /> < 600 East Main Street, Stockton, CA 95202-3029 <br /> M1ttGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/eh�p( ( .1 5 L007 UNIT IV <br /> P <br /> pc/FOR�� Well Permit Application Pv' _/'�; -� I,Vr <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Jf `' SFR',,,,ICES <br /> 1� <br /> (I,FS <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,/C'hapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location �!� ��• ITS dcl Cross Street E-1 )5U".4-city Sfoc��u✓� Zip Parcel#Assessors <br /> PROPERTY 1 <br /> Owner 6 , '> y{���.1vn Address yUs �, Cl ��,�f City Sicf Zip 9{Z 02 Phone# Ls2 f)43'7-Y N9' <br /> C-57 Contractor l-/'cr's+yn Sfniplr*, Address /l7?�l £ys�x /Yv`c City �w,. Zip o/ Lie#G3ole7 Phone# CAO,) .277-YSJs <br /> Consultant/Sub Cntr Gepon.rk.a Address I A5I E 411w—al City/-res„c Lic# Phone# LS,I(Y) zoo'!- 2535 <br /> GIS Coordinates:X ,Y—I'2i 1.,2-{reZ ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ELL/ BORING O,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) AtdESTRUCTION (choose type below) <br /> / SOIL BORING# 5e �.h u� /`t ,/ r •�,/1 % 0 OVER-BORE. DIAMETER <br /> (� WELL# �'� CS a PRESSURE GROUT <br /> *Other / GROUT SPECIFICATIONS I Yr�� YIGch+cw� <br /> � <br /> f o <br /> COMMENTS: /�i,�' A �lrti - v,,,h r, > � A — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a 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 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. 1 <br /> Signed x /� 1 Title/Company (�rp:+..r� �.+ co" /zti,77 <br /> Print Name Al-ex �e���� Date /0 -/)- 0 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /v Gv i4t VST <br /> WORK PLAN DATED: 41 <br /> Application Accepted By Date Issued AD—/ 7- 47-Area �+P <br /> Grout Inspection By D e 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 DAT PERMIT/SERVICE REQUEST# INVOICE <br /> 2 sB - 126// sR# D52 3l <br /> C-57-r/ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD29-02-001 WEB [.Qs 726 <br /> 9/11/2007 <br />