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San Joaquin County RSC <br />Environmental Health Department OCT 2 Z008 SITE <br />600 East Main Street, Stockton, CA 95202-3029SSAAN JOAQUIN couMTIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/esg�NVIRONMENTAL UNIT IV <br />Well Permit Application HEALTH DEPARTMENT <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 />Assessors <br />WELL <br />WELL Location (tZ-U'a-4 \- Cross Street � U`J �� City Ui l Zip Parcel# �� G <br />PROPERTY n�fi�_},� tri <br />Owner U A L1 i �\v ��,it Address "t l { � s �� L9 City Lr' 1 t �(n Zip t" 2�Phone# . 1.U..' q -tel t i1i?O <br />C-57 Contractor Address CityZip Lic# Phone#i7} — <br />.112.y � nSt X t 5�� <br />Consultant / Sub Cntr m, k t iii �4G � vw Address S Lis ie. _Zv City vim * Lic# �S�aS: Phone# <br />GIS Coordinates: X —t2 C " �I� YSO L`ii Township Range, Section f <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") Q DESTRUCTION (choose type below) <br />Q SOIL BORING # p OVER -BORE. DIAMETER <br />WELL # Q PRESSURE GROUT <br />Other U 1 111(711 (Y`ilt4u" jjL#%k iv' C. 1v1� GROUT SPFrr1F1r;AT1nNS ��� ►' -' <br />COMMENTS: doyei T tint 4y, iyV4a t4 , <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I'/ <br />D MONITORING jitIOLLOW STEM DIA. OF BOREHOLE Q MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: L <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 'OTHER: <br />0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D SOIL BORING a HAND AUGER GROUT SPECIFICATIONS (P o')&-1 LX yl l- l FRf <br />1bTHER: Vel* p OTHER APPROX. BORING DEPTH X 3 p BOLTED TRAFFIC BOX or XSTOVE PIPE <br />�yi j CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: --K A 1 0 f-' 1('6 � &Ai D' kcl <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 Ordinan*s R fes and Regulations, and all applicable California State Laws. J <br />Signed x :'"'41 J- 'T Titie/Company <br />Print Name_ =F' iL %-4 Date (tlt Z 1 l✓ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By� / 90" Date Issued D� Area _ <br />Grout Inspection By � p d$ Final inspection By �l <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REG'D BY <br />DATE PERMIT I SERVICE REQUEST # <br />INVOICE <br />C-57_ WC - ATVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EPID 29-02-001 WEB <br />9/11/2007 <br />