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San Joaquin County OCT 2 2008 <br />Environmental Health DepartmentSITE <br />600 East Main Street, Stockton, CA 95202-3029 SAN JOAQUIN couNITIGATION <br />ENVIRONMENTAL <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/A*kLTH DEPARTME 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 />t Assessors <br />WELL Location 32-'47- `' 'ice t it i z �1- Cross Street 1 V v City ^ M Zp _Parcel# L� L•�t <br />PROPERTYr, ti lY Aii���i'L' {�( ' -�—A i7/" raj !3 , / <br />Owner 4 Address v � City _Zip Phone# ±() - tJ"2a-^�-ca! pile" <br />C-57 Contractor •-LNS iAddress City Zip Lio# Phone# t,a1; -P-76 <br />:3`ft <br />�r � <br />Consultant 1 Sub Cntr 111t1�Zt 4x v� i �} Address u s 4e. ?C)L) City &'/j Z LA Lie# 1 3 t7(,± Phone# <br />GIS Coordinates: X"420" J V HO -X Y �� V tilt' Township_ i <br />WORK TO BE PERFORMED: <br />X -KEW WELL / BORING <br />0 SOIL BORING # <br />WELL # <br />Other —, <br />COM <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />Section <br />Il DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />!� <br />0 MONITORING <br />�NOLLOW STEM <br />DIA. OF BOREHOLE, 0 MULTIPLE <br />CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ _ <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC OTHER: 4F�' <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 <br />No (NOTE: MAXIMUM DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS (.,g.1r1`')�� <br />�FRREE-FALL <br />x Y tt a'l1 lLi. <br />ktTHER: Vel* 0 OTHER <br />APPROX. BORING DEPTH 30 <br />�'Y 0 BOLTED TRAFFIC BOX or 'STOVE PIPE <br />A <br />, r <br />CONDUCTOR CASING PROPOSED <br />(if YES, list specifications in comment section) <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 Ordlnanc*s, Ryles and Regulations, and all applicable California State Laws. <br />Signed x <br />Title/Company /4"SX<z,' <br />FEE INFO AMOUNT REMITTED <br />�'-' <br />Print Name G" f �"�= �� <br />INVOICE <br />Date Yom` t Cr <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By—I <br />Grout Inspection Byr <br />&.G�-ure Kd1 i Date Issued <br />�/-0 Date' �y 0�' Final Inspection By <br />Lp 2 D <br />ate <br />�- -�—Area <br />Destruction Inspection By <br />Date <br />COMMENTS 1 CONDITIONS: <br />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 />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EFID 29-02-001 WEB <br />9/11/2007 <br />