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r. <br /> P SAN JOAQUIN COUNTY .. <br /> ,. ENVIRONMENTAL HEALTH DEPARTMENT �1� j� TE <br /> 600 East Main Street, Stockton, CA 95202-3029 ( -aVVW�GATIOIN <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sicdo\cbrcj ' UNIT IV <br /> 4C7 FOR`' <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS�Lt�I�ONW-•!vT HEP'LlR <br /> �. ,`;�VICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appliL tibri iIso ade in compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> c Assessor's <br /> Well Location x`11 K `� :yh` Cross Street C.\cam rk �rv-Z City or�v� Zip Parcel# <br /> Property R rY`e c c r.�, <br /> Owner �x r rc� c �.c U�o Address City Zip -Phone# <br /> C-57 Contractor Address 3l �L Greer G`c� City ;���s.=� Zip c1S 1tiLLic#-li l S�y Phone k <br /> C1 sZi G3-,f� S'�i.'� i Z, c cLo? <br /> Consultant/Sub Cntr A'�.�,0�5 Address City t'0l5 c,:-�•� Lic# Phone 1\� \V S.• 1 <br /> IS <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> .NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# C•Jrz.\ S;&-t- ❑OVER-BORE DIAMETER <br /> WELL# XyNvv - 2.1 m-3- MV4-`A, r ml,i-`j ❑PRESSURE GROUT <br /> *OTHER — ' GROUT SPECIFICATIONS <br /> COMMENTS: <br /> S Z - k U n.c� M� -2_y mi.� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING -17'HOLLOW STEM DIA.OF BOREHOLE tJ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL �Y TREMIE TYPE TO BE USED❑AUGERS q HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:V Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> {SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 5�� r. Y�,'c� — 'M�X�y.Yc <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Z [A BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COND CTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMM ENTS:S6--Z �y ty�6 ,��� tlli►n♦ <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. I� <br /> Signed UVB Y,y�f� Title/Company N-41. k•. `Me�tv�c��.ti I INQ,.L-AIZ!,LC <br /> Print Name nNDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 q $r S• I-Iw <br /> it F n <br /> I La to <br /> WORK PLAN DATED: I Z. I 1 S 1 D e 1 t / a-- <br /> APPLICATION ACCEPTED BY DATE IS�S,UED, If L: AREA C <br /> GROUT INSPECTION BY �7�y�MDitivt b 11 a I eV FINAL INSPECTION BY-IC� �""��\ DATE 2f <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> p!;v 1 �9.�0 03 X 0 3 6 Gt1Z2 3 o1� S R# 513333 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT / ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br /> I <br />