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ET <br />N <br />San Joaquin CountyREC IVSD <br />9 <br />Environmental Health Department OCT 2 200 SITE <br />600 East Main Street, Stockton, CA 95202-3029 Ss OAQUIN COUNWITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ejVIRONMENTAL 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 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 34"17- `' ' ( ZU' S�- • Cross Street i V Cit �, m Zi Assessors ., <br />Y P rc Parcel# i �%G <br />Owner 1-0 <br />`i 'F �,if� Address �4q (A 'sa �` �L9 i1 city � r,-` m � ZipCIA i 70 -,hon. <br />C1 6�-50 'c ,x:10 hitt ,^ thn t el+fi- 3 "Sb k- <br />C-57 Contractor 1�J Address �t2.y 4anSt City Zip Lic# Phone# <br />�s ; <br />Consultant / Sub Cntr y1` L t�i{t` t)r A'Ci C/mj Address S is 4e. lk City R�� Lic# 1 3506-_ Phone# 7 !t _Shu -;yet j <br />GIS Coordinates: X'1�C ` i 0,0• Y U 4% Township 1 } Range 1 Section C� <br />WORK TO BE PERFORMED: <br />EW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") Q DESTRUCTION (choose type below) <br />Q SOIL BORING # © OVER -BORE. DIAMETER <br />VO(j PRESSURE GROUT <br />other r 1 I11 " ta�i*Y, S+ vvl� GROUT SPECVIC�AiTTIIONS <br />COMMENTS:. _ A ly, ,� ,iv e Ac, uj\' it <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS jf <br />0 MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC OTHER: 4' <br />0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />0 AIR SPARGE! OZONE d PUSH POINT (GP or CPT)GROUT SEAL PUMPED: o Yes a No {NOTE: MAXIMUM �FREE-FALL DEPTH IS 30) <br />D SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />jtbTHER: VeAA- n OTHER APPROX. BORING DEPTH 30 a BOLTED TRAFFIC BOX or XSTOVE PIPE <br />/� <br />( CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: A iblin'i r ke � &Ai <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 is, /Rfiles and Regulations, and all applicable California State Laws. <br />1�1Signed x �/ Title/Company ku% <br />Print Name y" �� f ", Date Li` t O <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />�/ <br />Application Accepted By /v P+ �1�1G l�% Date Issued C®Z Area <br />Grout Inspection By a� ,ZDate LO /3 Final Inspection By cam' /cYe lCJ <br />Destruction Inspection By Date <br />COMMENTS t 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 />73 I'D <br />C-57— WC_�WATVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />0/11/2007 <br />