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,..San Joaquin County <br /> oZ Environmental Health Department � � SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 n7 L�(�'.'-- I ,t'%I <br /> IVI�.��GATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd 2007 UNIT IV <br /> c• .P <br /> Well Permit Application AUG =J j <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS <br /> WD+=;'=iA �Q�rp it � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. -Mis appli1c ioh�i�M in compliance with San <br /> Joaquin County Devplopmept Title,Chapter 9-1115.3 and the Standar,�,dtt--of San aquin County E vironmental Health Department. <br /> 0-/ ,� Q`�� CWJAY � �klh� Assessors <br /> WELL Locatiog H4 L,0 I P� Cross Street City d; Zip �'� Parcel# <br /> 0, <br /> wOnerER , AddresS`4�oo` � � /� C' L Zip�6wPhone# t /v� <br /> C-57 Contracto I'A ddress SJr Pm"eG Ovr City ' A �S744 c#7r759hon41l�C�S9 1'01 <br /> Consultant!Sub Cntr Addres6 G? RA-Cit� Phone# 'r'i7 / IL()4 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHEW) DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# RESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS <br /> 00NITORING OLLOW STEM DIA.OF BOREHOLE -1-e'S MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA' l� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL&Q TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED (NOTA: M <br /> o AXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIO S <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ^�j�V`'`"� .CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:_ f,' WESA0 IM _c� � � F� f cf- R <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, Rule nd Regulations, and all applicable California State La S. <br /> Signed xVC82 <br /> Title/Company \ ,�� ' <br /> U k ��i►M lam/y' vc✓ Date ~r <br /> Print Name '7—�� — <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 10 4-Sr/tNo-f S4 L eCA i <br /> WORK PLAN DATED: Z <br /> Application Accepted By Date Issued O t T Area ali ZL <br /> Grout Inspection BDate 2-0 p Final Inspection By $ -Z j O <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# INVOICE <br /> 3� 6d o d <br /> 3s'o3 .00 Z6oYz 6-( SR# S 65 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_/ <br /> EHD 29-02-001 web <br /> 6/27J04 <br /> FILE COPY <br />