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i <br />San Joaquin County pp,YN�+�Ep <br />Environmental Health DepartmentRe SITE <br />600 East Main Street, Stockton, CA 95202-3026Cj 2 2008 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehdCOUN !T IV <br />SCOUNN <br />AN .1oAOUIti <br />Wel! Permit Application �{EALTHpEP RTE r <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct andlor 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 32Lt 2 5 • t i i S1V` � ... Cross Street �City Zip t Parcel# <br />OwnerPROP <br />U w 1 �� I C' €fit ^ i 2�' �( <br />�C ,� Address ?� t '�'fivE�L9 City�n Zip Phone# 1(}'t1"Jot K.ttltr <br />t�,�c <br />C-57 Contractor �J ' ' Address City Zip Llc# Phone# <br />' <br />Consultant / Sub Cntr M,kf Guµ3i (1 Address S a . ZkX� City + Lic#�1i35e�(r Phone# <br />GIS Coordinates: X -'12 V9 `� ZI y p Y rya U �i; Township �Jt Range 1 Section <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") a DESTRUCTION (choose type below) <br />0 SOIL BORING # p OVER -BORE. DIAMETER <br />WELL # \ 0 PRESSURE GROUT <br />Other 11 ; 'i i,11 ,/ _MNN• X �e it slhJ S GROUT °' �rjeICATIONS <br />COMMENTS: lip. _e� wmt �x <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING )1�`IOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: y <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL p PVC OTHER: t' <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE! OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: iMiAXIMUM �F�RREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ij'r Ai Y y1+&I IUs. <br />11 HER: "'Ii ' 0 OTHER APPROX. BORING DEPTHS&31 t� rh 0 BOLTED TRAFFIC BOX or STOVE PIPE <br />[ CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />.}� <br />COMMENTS: i A-c"I 8, Ike i _'Ii u_e ks <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 Ord1nan9ps; Ryles and Regulations, and all applicable California State Laws. <br />Signed x Title/Company l .SiL�v'X1� E '1 ve 1 jL'z 1e <br />Print Name = f'P - t Date ti i c -- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: _ <br />Application Accepted By Date Issued f�0 Area <br />Grout Inspection By _Aatee� ©g Final Inspection By���i2t�e <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT//SERVICE REQUEST# <br />INVOICE <br />C-57� WC= ATVER— <br />EHD 29-02-001 WEB <br />9/11/2007 <br />C-57 Letter of Authorization to sign permit_ Encroachment doc� <br />