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p� N�o <br />San Joaquin County <br />Environmental Health Department OCT �' 20 SITE <br />600 East Main Street, Stockton, CA 95202-3029 AN,.AOyIN COUN-�ITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org edVIRONMENVAL <br />HEALTH DEPARTMENT 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 />ice' Assessors <br />WELL Location 34`17 - S ' I& k �)Wk O S�1... Cross Street �� L`J �� City 71 L � kAA Zip ��Parcel# i�%C- <br />PROPER'L'Y , „ � t L t�1 <br />Owner I U �; i �� ��,�i�° Address ? "t t 9 �t City LV-�Ae l <br />�� <br />C-57 Contractor) ' `-• Address Citv <br />;+,- �12y Er'�Fi,rtSt- jiu�nli <br />Consultant/ Sub Cntr M, kf �Jr 4G f,/ A1J ,)Address S us 4e. -7y City <br />GIS Coordinates: X -I2 C� `� ZION Yya0 17 S�% Vii; Township !i <br />WORK TO BE PERFORMED: <br />EW WELL / BORING <br />Q SOIL BORING # _ <br />COMMEN <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />2 Phone# �. b U. I `! t ti <br />oq'�5 3 LI$,5 j � - t ,f! <br />p Lic# Phone# CPV -- r tf� <br />Lic# 35�?_Phone#ltl_u-jili�/ <br />le bn 3 <br />(� Section <br />p DESTRUCTION (choose type below) <br />© OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPE" 'CATIONS <br />V_, i <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONSI'/D <br />MONITORING <br />)<401 -LOW STEM <br />DIA. OF BOREHOLE, <br />Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL a PVC OTHER: <br />VAPOR <br />U MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />Q AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a <br />Yes p No (NOTE: DEPTH IS 301) <br />Q SOIL BORING <br />a HAND AUGER <br />GROUT SPECIFICATIONS <br />tMAXIMUM �IllFREE-FALL <br />,itt� Vx y1+&Ll RE <br />1bTHER:t'Iri OTHER <br />APPROX. BORING DEPTH <br />N1 BOLTED TRAFFIC BOX or XSTOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, fist specifications in comment section) <br />COMMENTS: <br />ii <br />gbw nl� R <br />e �i & f uxe aka <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 Ordlnancgs, Ryles and Regulations, and all applicable California State Laws. <br />Signed x /f T/�/ T ; Title/Company 14SXcii _&,, _ f` t9 1.I� ,"u le, <br />Print Name Date tl t U <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By . /U9./� J7L{i�+ t / �"'C y Date Issued l� Area <br />Grout Inspection By Date_ �o��� Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT 1 SERVICE REQUEST # <br />INVOICE <br />8'3r� V <br />j°l�®1 S!&�� <br />C-57— WC_ -WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />0/11/2007 <br />