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San Joaquin County • <br /> Environmental Health Department I ������IU/� SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 T`GATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd MAR 2 0 2008UNIT IV <br /> 9�rFORN`P Well Permit Application EIWIROIVft-?EP - <br /> !1 HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or 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 /> II \ l r' Assessors )g5-02-13 <br /> WELL Location 2 929/ZgT�tiil�tTh 5'I- cross Street�✓'' U��c city SlucF'I'u1, zip g52 <br /> 0 <br /> 3 Parcel# I Ks-oz- 7 <br /> PROPER / 1.l I �,(� <br /> Owner 0/� Or S}xktDh Address 2201 W•t�WSS�ingr}Oy City C�1 n Zip 95 3 Phone# 2or7- f�6-�yd <br /> C-57 Contractor6"11 Drdh�Address `i.SO Howe rd City Zip q` S3 Lic#y?5'95-Phone#92.5-313-5804' <br /> l;QM •WYt� Tec. 2525 St ? sf <br /> Consultant/Sub Cntr r Address Dn r Sul+/ ;s 4rk City en7wnl+L/ic# AIAn Phone#9/6 J?2-Y-6)378 <br /> GIS Coordinates:X ,Y ,Township_�C T/pR g Range S�� Mtf' V15L)0 Section <br /> WORK TO BE PERFORMED: <br /> `RQEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> 11 SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL#: Olu-1 freact. W-4 O PRESSURE GROUT <br /> n"Other GROUT SPECIFICATIONS <br /> COMMENTS: 4 t,j11S �7" dviwlr+w) fu 6 tNSW(4 VSA HSA <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING >NOLLOW STEM DIA.OF BOREHOLE `` ��u B MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> B EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS7o� q r. TYPE OF CASING: a STEEL )PVC a OTHER: <br /> f <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL N5 {C'E TREMIE TYPE TO BE USED: AUGERS B HOSE <br /> a AIR SPARGE]OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: u Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS L <br /> B OTHER:_g OTHER APPROX.BORING DEPTH D OOLTED TRAFFIC BOX or u STOVE PIPE <br /> CONDUCTOR CASING PROPOSED t�10 (if YES,list specifications in comment section) <br /> COMMENTS: g0t/t/r �,.pi.. ! 12-'7-1.) a-. C 5 f et A 12:-� f�" 1 4" / ✓ 2-r A" <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 pxe ared this application and that the work will be done in accordance with San Joaquin <br /> County Ord*h c s an Regulations, and all applicable California State Laws. L <br /> Signed Title/Company !ENro- ccdvglf( <br /> PrintName�"1A `1 �CN.pp�1"r'p Date 3 SOB <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:()-5 L✓, 1✓4s ky.Y7, 5I- P81 At, <br /> WORK PLAN DATED: /l)el/: Z,007 <br /> Application Accepted By� Date Issued 3/21/0g AreaTT 7 <br /> e <br /> Grout Inspection By DateSt I t 15'9 Final Inspection By Date <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 /> /-br 85 /oslSv l uSR#oo� g7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> PRO 29-02-001 WEB <br /> 9/11/2007 <br />