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pA v <br />San Joaquin County OCT 2 2008 <br />Environmental Health DepartmentAN JpAQUIN COUNTY SITE <br />600 East Main Street, Stockton, CA 95202-302 ENVIRONMENTALITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgi�IJc�H DEPARTMENUNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM HATE 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 />WELL Location 3Z� i 2 5 C t Qi Ya ` N- Cross Street u 'e_ Cit (�y,,y, Vt Zi Assessors <br />�' Y p _Parcel# 0—1 b i <br />t �t , /ivy <br />Owner u f�:ll�y Address "� t i� '�� g City LK' s l Zip i��Phone# f(}"`( - Yoi yYtLf�f <br />\�Y"t'G 1 �(" C3 "14�ii p �1 � <br />C-57 Contractor_�l ' _ °�-� Address Citv Zip Lic# Phone#��� <br />ni 1 z.%1 4v.y .R St I'hr�rt\ <br />Consultant / Sub Cntr M, kkY 'N- 44G � Address S U s 4eA 2 n City `�c <br />GtS Coordinates: X _i�C `� �I U -�C, Y 1 Township $ <br />WORK TO BE PERFORMED: <br />EW WELL 1 BORING <br />0 SOIL BORING # _ <br />tl WELL # <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />)7"1 l9 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS id <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: 0 STEEL 0 PVC OTHER:�' <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: p Yes p No (NOTE: MAXIMUM �FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS S t'yyle_—A irti ti 9 L42 <br />kbTHER: Vel* 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or STOVE PIPE <br />�`` <br />j j CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS:_a A �1�� � �J i-' ke <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 les and Regulations, and all applicable California State Laws. <br />/� <br />Signed x �/ Title/Company j� � iv% �s� $"1 %e,, <br />Print Name �' .J� ff/12 Date v i L,;, <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By�77 4i6 7>�� Date Issued �g �-��-Area ----i <br />Grout Inspection By /G'a�oG C' c Date_ G� /Y �8 Final Inspection By �, irc@ate_Ya <br />Destruction Inspection By Date <br />COMMENTS ! CONDITIONS: <br />11 ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />�fl� <br />VM1, s (3-f -- <br />f Ri-O `�1° <br />Lnr S _ <br />j_ <br />C-57_ WC= WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EFID 29-42-001 WEB <br />9/11/2007 <br />