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n Joaquin Couilty f IL E COPY <br /> y Envir ental Health Department 0�� V �L� SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 LL55 V ITIGATION <br /> o P ' (209) 468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT IV <br /> Well Permit Application F�J�/AUG 1 4 2007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS RUNMENT HEALTH <br /> RMIT/�ERVIGES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. his app ication is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11115.3 and the StandardsR f San Joa uin County Environmental Health Department. <br /> yyoS 7AC IFlt- ryV }ACIfi� �VC � Assessors <br /> WELL Location CDrC,Cross Street 5jaAKyV RD, City cST0C.K7t)n Zip 9I5Parcel# <br /> PROPERTY //)) n _ <br /> Owner :)FRAU Cf}S�FiO Address_` Y05 T/4CiF)l- /'7V2.City 5i9c l)Zip2sdO phone#_ZoW 9715 - SSCL� <br /> C-57 Contractor Mi1gjhe/1)) dlAddress79C0 N1yAVP �ve . City a tCF'1 Zip`��3Lic#67a(o/JPhone,,,, �J7 gvy-9oyo <br /> Consultant/Sub Cntr 77 G ,�- Address�37 c$-,mt\A/ R d City 5&0-K'D,%Lic# 1630 ZZ 7 Phone&9 MLZ^^l99 <br /> GIS Coordinates:X31- C ap8 y -12-1. 3 I`0pTownship Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> SOIL <br /> UW-1 �JW-2� 1/W^�i aPRESSURE GROUT <br /> O'Other `jyQ / /,y1�R U f� GROUT SPECIFICATIONS <br /> COMMENTS:_,SF_F_ Farb-/Ynk/el/) w D r� ?L'j, DO'] MR Z0' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS L�� <br /> 0 MONITORINGOLLOW STEM DIA. OF BOREHOLE /n' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_/____ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SLP)4 a ON)e TYPE OF CASING: 0 STEEL *VC 0 OTHER: <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL (o ' TREMIE TYPE TO BE USED: 'AUGERS '*OSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Y/es Xo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 4UTL09ND IPC- <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 5 ` $'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C NDUCTOR CASING TOPOSED l� 0 1 (if YES, list specifications in comment section) <br /> COMMENTS: 5EE- F)4jD P' , lel ,_.r I.A,TF fJ C)R '122& Z-Qn"7 <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 C/ Title/Company O fl NA LE <br /> Print Name ' T4 Date FS <br /> DEPARTMENTUSE/ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Wo!5 BL <br /> WORK PLAN DATED: -O <br /> Application Accepted By Date Issued O b- Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> I� /f 530,` 2fo050 g . 1� SR# <br /> C-57 % C�- IVER*A C-57 Letter of7�A,uuthorri�iz�at..}iio�nto�sign <br /> �permit Encroachment doc_ey <br /> EHD 29-02- Olweb J� <br /> 6/22/04 l� <br />