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San Joaquin County `r'o <br /> Environmental Health Departp����{��� SITE <br /> 600 E. Main Street, Stockton,CA 95202-3 91_ lt1! ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd 2010 UNIT IV <br /> Well Permit Application .�a,1 <br /> EWT NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE S{WSSERVIGE <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descri etl. 1TYhriis1 application is made in compliance with San <br /> Joaquin County eveeJJopment Title,Chapter 9-1115.3 and the Stanrr��rds of San Joaquin County Environmental He lth Department. <br /> Grr� o1 ti+r5 -en G,ry J'Tr. oa Y.jtir�f't+-<y Sce- 1 cr�t� p� Assessors <br /> WELL-Location y99 W ChAfT/� Cross Street r r. e r City STneLtW Zip CJU6 Parcel# 16335o o,4 <br /> PROPERTY <br /> Owner RTYf7`crlrlrVddress(2500 tl-- Prr City 5tccI.trt^ zip -5ZA,6Phone#?�� 937—F7V <br /> Ft S <br /> C-57 Contractor c M 1n✓ &r�' Y- dBress 3c)j Sher;i Akce- City 10, h'}. 95z5YLic# Phone# -19610 <br /> Crt S_5 <br /> Consultant/Sub Cntr C6 rr EAp/�TP dtlress jS8 Frz,,.jr W�sT cry ,1S/r��r�,Liae Phon o L -o SIB <br /> GIS Coordinates:X_ 63Z32L J8Y-71618 9 I•9 5 ,Township !✓ Range �_Section <br /> WORK TO BE PERF G SCC ATT+c, <br /> n NEW WELL (CP GEOPROBE YDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION <br /> (choose type below) <br /> 0 SOIL BORING# <br /> 0 OVER-BORE. DIAMETER <br /> 0 WELL# p PRESSURE GROUT <br /> ,ErOther�c-7 rc. r�rr inn _ 4-c.r"f St,yil r�n-a�� tiy- y 16ce T"rjkA5 GROUT SPECIFICATIONS <br /> COMMENTS: oz l r7 ti^d IC -reel Y be ltc,1e,15"r4cc— <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_j" D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL 0 PVC n OTHER: <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL L5-10' I7S TREMIE TYPE TO BE USED: D AUGERS p HOSE <br /> n AIR SPARGE/OZONE A.PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS lJt��Rer4low� Cdnn+4.K'� <br /> 0 OTHER: R OTHER APPROX.BORING DEPTH I S- STLsf` 0 BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CO/NrDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: L I rkre..Q. (eC <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 Title/Company - C I-eo4WG t <br /> Print Name <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S I;v Vj rLv-fi <br /> WORK PLAN DATED: tI e <br /> Application Accepted By Date Issued S 1 S' ! C7 Area <br /> Grout Inspection By Date 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 DATE PERMIT/SERVICE REQUEST IN <br /> L9cq �_a� $�,00 t toS L! c� SR#S <br /> A- <br /> C-57,Z WC , -WAIVER_ C-57 Letter of Authorization to sign permitf-_�Encroachment doc_ <br /> X 29-02-001web <br />