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p,; ..'• San Joaquin County. <br /> ❑ V11 <br /> . '-,la z Environmental Health Departme" SITE <br /> T. s .� .. - <br /> `�: 600 E. Main Street, Stockton, CA 95202-3029L�InITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or <br /> c' , 2 *� 2D07. UNIT IV. <br /> Well Permit Application ENV1RO� IVT <br /> HEALTH <br /> NOH-REFUN6ABLE PERMIT EXPIRES I YEAR FROM DACE IS� �rISERVICES += "'• rr <br /> J <br /> Application is hereby made to San Joaquin County for a permit to constructandlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 12�d2'S�1 v� ti-�1 Cross Street � � "4 City Zip-- Parcel#2L4 30-7D 1W <br /> PROPER RID <br /> Owner` IQAI A Address,'3';!7Q N 1 ` � Citjr V1UL ' /J Zip f:S Phone#Doj-11 + <br /> C-57 Contractor V (�Sl'b ��nY,1 M Address90�x 117 City t_ �f Zip ("l <br /> Li r ' Phone# ll0 1�J <br /> Consultant!Sub Cntr��tt l U V UlfV'J �AddressP ,Y 1�J City a� )d ic# Phone# �` 'f 1/-,)l <br /> GIS Coordinates:X- - 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER;OTHER`) ' p DESTRUCTION (choose type below) <br /> 'SOIL BORING# a OVER-BORE. DIAMETER <br /> g WELL# y - © PRESSURE GROUT , <br /> 0`Other - .� GROUT SPECIFICATIONS <br /> COMMENTS:00 Y\\1 AD W 4'5>L w6�'�v. jj Cp1"60L-vv-d- u)s 41 '1 n5 aRj^ k-- <br /> TYPE OF WELL INSTALLATION TYPE ' yCONSTRUCTION SPECIFICATIONSrq P >. Z�f <br /> MONITORING 'HOLLOW STEM DIA.OF BOREHOLE n:0 MULTIPLE CASINGS p MULTI-LEVEL WELL,CASING DIA:,_�_ <br /> ©EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNES8CA,1� TYPE OF CASING: U STEEL 1VPVC . Q OTHER: <br /> a VAPOR i]MUD ROTARY DEPTH OF GROUT SEAL r �1I� E TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> 0 AIR SPARGE)OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes No Nof�(�NOT MAXIMUM FREE-FALL DEPTH IS.30') <br /> a SOIL BORING o HAND AUGER'- � GROUT SPECIFICATIONS 1y <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH L�� I VBOLTED TRAFFIC BOX or Q STOVE PIPE <br /> :. CONPU`C,TOR CASING PR POS (if YES,list spec"ications in comment section) <br /> COMMS TSL'lfil� CAL'�C�rtV�1��3�1i1\. a�C' i <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 pre0a ed this appli •on and that the work will be done in accordance with San Joaquin <br /> ftles County Or Ina e an a ulations_, nd II applicable California State Laws. <br /> Signed x TitlelCompany(�r-7777 <br /> Print Name �Y ` re)7 Date �Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: t' ri' a-v <br /> Application Accepted By Date IssuedM1 ! 12 /0 Area <br /> Grout Inspection By Imo, Date i 1-7,f0d Final Inspection-By Date .. <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID#. �` :FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK"# ,.. 'REC'D BY DATE PERMIT/SERVICE REQUEST#: INVOICE <br /> 3s0l ,a SR# �'Z �Z <br /> C-57 _ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6!22104 <br />