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FILE COPY <br /> SAN JOAQUIN COUNTY <br /> G <br /> OU <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> t600 East Main Street, Stockton, CA 95202-3029 TCa T - <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sjgov.orWehd REI „ <br /> 9(iFosr./ �++ <br /> WELL PERMIT APPLICATION <br /> C'65 ^011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ane,. co TAI <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is V FakT&h' LTH <br /> Joaquin County Development Title,chapter 9-1115.3 and t t�ndarSdqASan Joaquin County Environmental Health Department. PERMIT/SERVIC_ <br /> lei tt�� / Assessor' �7 <br /> Well Location�Giy�t„ + t Gross treet l,J City Zip -5-3 Parcel# �I <br /> Property <br /> Owner Of- Tr Address _L_�j1�GyL�lg3� City Zip�53 Phone# - 3 <br /> tra53c)-&61- <br /> C-57 Contractor Address a 31g�_r41It <br /> c . 5C <br /> /• ,�(A.tk Q City Lic#� 0 Phone S -&n�Q <br /> Consultant/SubCntr,�L�,>�s Address 1101 12 City Q Lic P/ Phone �` 33 <br /> GIS Coordinates:X —IZ4-432 ,Township Rang Section <br /> W RK TO BE PERFORMED: <br /> EW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#T Y/ •J 11U'!J 111V4;31XJ'!.7-�7 Yu-5, TJZyIJ'7 TI 'lJ'8 ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> ❑ <br /> *OTHER <br /> /I I y�q GROUT SPECIFICATIONS <br /> COMMENTS: lOCA.�-1�Ov1S 65/ 'l2 1 OIl L01/'tV\ �T Y�� T& 3 TRYD-Y,101J"S ff- j'i <br /> 2 to �L.J `u Y '1 t .d !J- <br /> 'j11 V <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ` <br /> ❑VAPOR El MUD ROTARY DEPTH OF GROUT SEAL ✓ TREMIE TYPE TO BE USED❑AUGERS El HOSE <br /> 2' <br /> ❑AIR SPARGE/OZONE PUSH POINTOR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ` <br /> ASOIL BORING HAND AUGER GROUT SPECIFICATIONS T�1 <br /> ❑BOTHER: ❑OTHER: APPROX.BORING DEPTH n�J — [1 BOLTED TRAFFIC BOX OR ❑STOVEPIPE <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 /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap licable California Laws. <br /> Signed c Title/Company'4/yEc <br /> L[ -0- <br /> Print Name e � �l Gi� Date3 ��.�U <br /> DEPARTMENT USE ONLY n• / �9,'/1p <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Al 6 <br /> WORK PLAN DATED: Z 32zi 0 <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA vo d <br /> GROUT INSPECTION BY _ _ FINAL INSPECTION BY DATE �I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ow 47 r <br /> ACCOUNTING ONLY: AID# FAC# l <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> & -110-11sR#D 7,3S(O <br /> C-57 WC V -WAIVER C97 LETTER OF AUTHORIZATITILE <br /> TO SIGN PERMIT ENCROACHMENT DOC ►� <br /> EHD29-01 1115/07(WEB) / 0 w/ 7 <br /> 7%5 9D3 <br />