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/rourry N6an Joaquin County FILE COPY <br /> Environmental Health Department 'TE <br /> } LMS ATION 600 East Main Street, Stockton, CA 95202-3029 <br /> 1 (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chd ,_ , , <br /> 20 <br /> 00 IV <br /> Well Permit Application ENV�RC� Mrv;�T HEALTIH, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P�.RMI USERXES <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 /> Assessors <br /> WELL Location 33`� F15-L A41-11") 6t Cross Street City 2i/�OMti Zip �sJl6� Parcel# 61- j50-'i <br /> PROPERTY f3 <br /> Owner Cke-yy'nn EAA C Address P 0q. f3o3C Cc/,)- City`Jo-n kcmohZip 91583 Phone#9a15-'8''fd-`79S R <br /> C-57 Contractor ri r vt Address / SO Howe Rd. C1tyMaLic#185765Phone# V 9 3/3-S800 <br /> R pr. <br /> Consultant/Sub Cntr G/`� AddressaOdD �OOor✓war h �/84City pSeYr%!e Lic# Phone# ;L-34/0 <br /> t <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,'GEOPROB , HYDROPUNCH,HAND-AUGER,OTHER`) [] DESTRUCTION (choose type below) <br /> J SOIL BORING# VP-1- 42=,2 - V'✓_a []OVER-BORE. DIAMETER <br /> []WELL# 7� []PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING [)HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS A/M _TYPE OF CASING: []STEEL 0 PVC 0 OTHER: <br /> VAPOR []MUD ROTARY DEPTH OF GROUT SEAL Eft TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE III PUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes N No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS T'�Pe- 1/o2- Por-bI C- )d ceme»-, <br /> Q OTHER: []OTHER APPROX.BORING DEPTH 6-4 y []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /1/0 (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. <br /> Signed x v �f✓�G �� Title/Company sta '� Geo <br /> Print Name Willio-m McLrt:;ne27 Date 1111910'A- <br /> DEPARTMENT <br /> l/l91G�DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �34' EQ } Ma art 0S+. , yea n <br /> WORK PLAN DATED: &r,be-r- )t a o D? <br /> Application Accepted By Vj r+nria UnXirf-4y Date Issued - ( — (} Area 14. <br /> Grout Inspection By Vv C-or`r e_rY1 L Chi r 3MAh Date I-17 -0 Final Inspection By ��e.fisr r' ? Date /—J 7-d 8 <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 /> 3501 12rS9. 00 9900 30 // '7 VW SR# 0026 72 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />