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0 0 <br /> U)N San Joaquin County o <br /> '� Environmental Health Department �i5/ TE <br /> e °� `NSW <br /> WPM <br /> 600 East Main Street, Stockton,CA 95202-3029 N <br /> (209)468-3449 Fax: (209)468-3433 Web:wwwsjgov.org/ehd 4P� j 1JNI <br /> Well Permit Application ' r V1 %4- <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM�r�t:'V'T HE, <br /> i[j� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ma <br /> pliance,with San <br /> Joaquin County Development Title,Chapter 9-111155.3 and the Standards of San Joaquin County Environmental Health Department.Assessors <br /> WELL Location v <br /> IS6,3Lf S-ttiyegvl heocl Cross Street Lon- lfe<RccflGJcy o✓I zip Sq 3ZO Parcetk?71-I20-01 <br /> PROPERTY �S r�lo✓I Zips yz0 Phone# 838--1�ds5 <br /> OwnerAllxrf *iJgr (a ✓t(r&, Address r�X2NS I��r~� City <br /> C-57 Contractor r 35 <br /> �--Addresses 5 O }�-owz_�c7a_d City '✓i Zip L5i� Lic#&Af�}Phone# 92631 -5900 <br /> U <. ,.H City fOLic# Phone#ZA9.5-7`/-ZZZI <br /> Consultant/Sub Cntr A�9ocia-te5 Address 1111 Len- <br /> GIS Coordinates:X <br /> y.,TownshipRange Section <br /> WORK TO BE PERFORMED: STRUCT <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 OE ER BORE.I DIAMETER oose type below) <br /> XSOIL BORING# C C'PT g PRESSURE GROUT <br /> U•Uther <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ` ����� <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2� a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: ry r'r' <br /> o EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS IVF TYPE OF CASING: 0 STEEL 0 PVC B OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 130 ' TREMIE TYPE TO BE USED: GAUGERS p HOSE <br /> p AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes _p�� � AXIMU�M FREE-FALL DEPTH IS 30') <br /> ''SOIL BORING a HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER: g OTHER APPROX.BORING DEPTH 130 <br /> CONDUCTOR CASING PROPOSED (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 /> 1 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 /> n //��C <br /> Signed z �+s�ca G�tS <br /> j <br /> Title/Company ] ✓'4y�ch r' V`Q�aS� ' <br /> Print Name <br /> `JGA11hL POm c r Date O[ ioZloh <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S <br /> WORK PLAN DATED: <br /> I A\ Date Issued 2 t 0 Area <br /> Application Accepted By — Date 2S O <br /> Grout Inspection By )iQt� <br /> Date--�4z1�Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3sor 4 "'00 00}qSR# ro CA D <br /> 3�3 9124 •00 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ <br /> EUD29-o2-001 WEB <br /> 9/11/2007 <br />