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z v T <br />San Joaquin County OCT 2 2008 <br />Environmental Health DepartmentN JOAcu,N couNTY SITE <br />600 East Main Street, Stockton, CA 95202-30 ENVIRONMENTAL MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: WWW.sjg0V.CFgjVjW 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 />Assessors <br />WELL Location Cross Street L`J re— city �h&Qm Zip qSZUO Parcel# <br />PROPERLY : �U ��l�Zlp���Phone#Owner �(r&"'y�'�}^ ik4a <br />�31�.-.4q� <br />c-57 contractor 1 :tri �l, qt ltt i tits kS� 0; - <br />Address City Zip Lie# Phone#a�ft <br />P r tT� —` <br />+ t 2y I St )Ad <br />Consultant / Sub Cntr mi. kW 044 t Address S u 3 4e. 7W City Lic# 3S L Pfione# <br />GtS Coordinates: X �,2 V `j Z L�, Y6 iJ 0 1`n Township 1�_ Range 1 �' Section <br />WORK TO BE PERFORMED: <br />EW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />Vo# 0 PRESSURE GROUT <br />other > f 11 t ` tY1egfur`-t ii&AhV' S vl j, GROUT SPECIIFFI�CA IONS <br />COMMENTS: A - I A C-1i'ye, uj%' O �Y. i�i j ��{ `„ r— �S <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !� <br />0 MONITORING )�`IOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL G PVC OTHER: 4�' <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: MAXIMUM FFRE <br />REE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �';t GM_ <br />�bTHER: )� OTHER APPROX. BORING DEPTH ?_ 0 BOLTED TRAFFIC BOX or 'STOVE PIPE <br />('� j ( CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS:' T3 ��in-1 ot-` I r o V _--ai t o 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 OrdinanS*s, Ryles and Regulations, and all applicable California State Laws. <br />Signed x Title/Company/IWi�ii%4f, <br />Print Name Date Wt <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />01 <br />Application Accepted° �_i1P U�3o'/�c. YfS,r! Date Issued /lJ a/ ®•O Area <br />Grout Inspection By �`'� 4-Z� Date ! VIYI©9 Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />ka <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc� <br />EHD 29-02-001 WEB <br />9/111200,' <br />