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#ro <br /> `dan Joaquin CountyEnvironmental Health DepartmentSITE <br /> 600 E.Main Street, Stockton,CA 95202-302,pl ET .9rIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov LL��22010 UNIT IV <br /> Well Permit Application APR 2 0 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE�RONMEN❑rTr����H�yEEr��AAfLf�TTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work the wo �tI� GIq�tment�in complianceOhs�n <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards ppi Saan Joaquin County Environm ntlaylt H a t eparlmentAssessors /63'3X-001- <br /> ftC 47-r-C. <br /> CT C <br /> WELL Location�- /V"YV�_Cross Street I /I % LGw.Aity -5 -41kn Zip SZA Parcel# f oqo((, <br /> PROPERTY / 'I -S'7'10 <br /> Omer_�I�� O�j TocI'A'1 Address 2.S0a f✓..VVO Clty ; ort Zip jj�tV Pho <br /> C-ST Contractor <br /> �iSC1En Vafenmutc�Address 399 Sh et�'s PkcG City1GII /� Zip95LLic# Phone40 76 1Dvd <br /> Consultant/Sub CnlrCond OrF•+r Tich. Address )'88Fr.�rrR b'rrfTrrsc;�y T �n Lid' Phonen�Zaq�Z3Y—OS/$ <br /> GIs coordinates:x b3Z2g�q.8A Y 216t 2661 0 y ,Township I Range 6 C Section ( l <br /> SG G K rT-,a"e-G <br /> WORK TO BE PERF M�! <br /> p NEW WELL/ (CPT, EOPROBE HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> p SOIL BORING# a OVER-BORE. DIAMETER <br /> — <br /> a WELL# t t B PRESSURE GROUT <br /> #Other c 't' S�d,Ar4, <r� "a Iacc tiQnf GROUT SPECIFICATIONSgg Ila - 5'—l0_9d U^rtr <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2" a MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL B PVC BOTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> p AIR SPARGE/OZONE ;,PUSH POINT(GP or CPT)GROUT SEAL PUMPED: E Yes a No (NOTE: MAXIMUM FRE FALL DEPTH IS 30') <br /> aSOIL BORING OHAND AUGER GROUT SPECIFICATIONS l_ Ddkt�OT` (-L"^" r <br /> p OTHER: D OTHER APPROX.BORING DEPTH t S- LA'Y a BOLTED TRAFFIC BOX or E STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> �T <br /> COMMENTS: A I 1 ` e!t* kT fit np[Qias)& 65:rIJ Sr w*b rJ T4.E l7 L C51 J)1 L 0".1. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules ann9 Regulations, and all applicable California/State Laws. <br /> Signed z Kd u Title/Company�/7 <br /> Pnnt Name 01"I d5;�A n k _ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: iso VJc vti v� <br /> WORK PLAN DATED: o' 5 l�� '�o'^�' " °OI <br /> Application Accepted By /i /un�w' y Date Issued ] S ' ( J Area <br /> Grout Inspection By ` Date Final Inspection By 14 Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> EACCOUNTING ONLY: AID# FAO# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �1,oJ g�.9� Orli S SR# 5� 8 <br /> C-57_ WC-:WAIVER- C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-901web / <br /> 6122/04 <br />