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F� <br />San Joaquin County <br />Environmental Health Department coutA v SITE <br />604 East Main Street, Stockton, CA 95202-3029 Sp,NNW,ao M a1M�A111TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/e k'5' DEPA UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />WELL Location 32't2 ' ' t't1 1 a 0 1.- Cross Street Nki re- city 7U`.�rVzip �Assessors <br />Parced# biPROPfiL-�i <br />ERTYr f�f7""Phone#OwnerAddress -'S�}(,omi LC9 � City LV VHetZip tom2 <br />IV_ <br />\�lt'c�G H��a <br />C-57 Contractor * f Address City Zip Lic# Phone# <br />+ <br />1),12.1 4v�i' n S+- <br />Consultant / Sub Cntr Mt k iJr 944 � Address S. Ls t 4. -UX) City�i�cQ Lic# 35 Phone# <br />GIS Coordinates: X -�Z C `� Z ►.{).5, Y� U Township 1,3 Range l f' „t Section <br />WORK TO BE PERFORMED: <br />PE CODES <br />'I EW WELL ! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') D DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />0 OVER -BORE. DIAMETER <br />WELL # 0 PRESSURE GROUT <br />Other kl• - II' ` I zA\.r S v�� � GROUT SPEP-IPPATInNS <br />� <br />c <br />I <br />COMMENTS: <br />� <br />r')�(?t kU\Il 3 <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />L <br />0 MONITORING )I�iOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br />0 EXTRACTION Q AIR HAMMERIDRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC OTHER: <br />0 VAPOR 0 MUD ROTARY <br />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 p No (NOTE: MAXIMUM DEPTH IS 30') <br />ij SOIL BORING 0 HAND AUGER <br />�FRREE-FALL <br />. <br />GROUT SPECIFICATIONS Y'it! �X d1+ I1 tLt <br />bTHER:li ©OTHER <br />APPROX. BORING DEPTH / f BOLTED TRAFFIC BOX or XSTOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: tb� o I <br />t <br />(o V {tai k, - tks <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 Ordinanr*s3 RA,les and Regulations, and all applicable California State Laws. <br />Signed <br />Title/Company. <br />Print Name �' �' 'Q- (• lt` r' + Daie lLi(� f '✓ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />42�W Date Issued 4�O9_ Area <br />Date Final Inspection By ' Date 14-'I-CJd- k <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNTREMITTED <br />CHECK # REC'D BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE <br />F,3 (Z.) <br />`Ji�(7�i $ RM/ll�� S <br />— <br />C-57_ WC—C-57 Letter of Authorization to sign permit_ Encroachment doc� <br />EFID 29-42-001 WEB <br />9/11/200," <br />