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" oo San Joaquin County <br /> Envin—amental Health Department ' SITE <br /> { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> j <br /> ` IC ( 1r i ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehY)� LC' '=- I' V NIT IV <br /> COP'S <br /> Well Permit Application MAY 1 ;, i69l <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 - , H' q l <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This qqQ ] t `Gompliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental HeIth MC drtment. <br /> Assessors <br /> WELL Location 222y l� �. Cross Street �J. VL' }, CityZip ,ISZO� Parcel# 1�!3 I -U 7 <br /> PROPERTY <br /> Owner qoL� tt Address 2224 CiZip 25z06- Phone# (761) <br /> C-57 Contractor C recc Ddu. Address 956_ 3 -City 4 '� Zip 9Yss3 Lic# `�Phone#/9z5)j13- <br /> Consultant/Sub Cntr-A (-en ,Cn 4n I Address X37 Inc w Qom. City C-tdc✓4o,\, Lic# 6�. Z 7 Phone# (1611)q%?-10,1C <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# <br /> WELL# S Q OVER-BORE. DIAMETER <br /> Q PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: 5- &od t)],, -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE R„ Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: Z" <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS n TYPE OF CASING: Q STEEL , PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 4 ( G TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS.- I/1T <br /> Q <br /> OTHER:_a OTHER APPROX. BORING DEPTH 3n' / 90' XBOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED vu^ (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 a Title/Company /AC-.�P_ <br /> Print Name -J a` I C.iLa.o ^- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2224 Man+h e v 71 o a d <br /> WORK PLAN DATED: relorua r ., 2C 2 0 07 <br /> Application Accepted By�_;_C,'ter iLl_ L t+ L►r+n �u Date Issued - Area 145-q <br /> Grout Inspection By V:t+"j 4 `'YjA Date O I Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: r <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3S-01 89 374. bo 2577 /D sR# 40 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 4n1ma <br />