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vEi� <br />R <br />San Joaquin County 2 ZOU <br />Environmental Health Department OCT SITE <br />600 East Main Street, Stockton, CA 95202-3029;AN JOAQUIN COUNTYVIITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orNVIRONMENTAL H DEPARTMEN 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 />}} �r- Assessors <br />WELL Location 32 12 5 1r (�� zj- , Cross Street 1W1 �� City ZAA7ip " t5 Z4 _Parcel# �� LfiL•�I <br />PROPERTY } t �L t <br />Owner r, ,—f {vi� ��,1fsG Address ? � 9 �t CityLV;i`AHf� Zip�0Z'"Phone# � q mol <br />( <br />C'1,�iC�� p'let,~t��►t�3 <br />C-57 Contractor -- Address City Zip Lic# Phone# <br />tt A 12 .k -j 4''�' 11 St - <br />Consultant l Sub Cntr m -kW � A* � AV Address S v s 4e. 7W Citv �i� Lic# i�3 a � Phone# <br />GIS Coordinates: X -I2 t; 2! �� Ya +✓i;P Township 1 Range lz' �` Section <br />WORK TO BE PERFORMED: <br />EW WELL ! i30RING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />n SOIL BORING # <br />COMMEN <br />�}.� <br />i1AI� �7_ i'A%A-a <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />i /"I-/— 11K .?-& <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />j/ <br />L <br />0 MONITORING <br />jl�f`IOLLOW 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:' <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 { <br />�FREE-FALL <br />uyy)' tl Irk Y1 ) I ltt <br />bTHER:�� 0 OTHER <br />APPROX. BORING DEPTH 30W_ <br />0 BOLTED TRAFFIC BOX or XSTOVE PIPE <br />CONDUCTOR CASING PROPOSED <br />(if YES, fist specifications in comment section) <br />�' <br />COMMENTS: -rY A <br />j j <br />—TbW 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 OrdinanWs3 Ryles and Regulations, and all applicable California State Laws. <br />Signed <br />Title/Company <br />Print Name I ` . S' rd- ( Dateti f t l Ua <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By /W116 <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />Date Issued Z/ $ ��4► ,—,� Area _ <br />,722—Final Inspection By dU6�'�te 1---x,-1370-7 <br />ACCOUNTING ONLY: AID# FAC# <br />ES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT! SERVICE REQUEST# <br />INVOICE <br />Z <br />C-57 WC -WAIVER <br />EHD 29-02-001 WEB <br />9/11/2007 <br />C-57 Letter of Authorization to sign permit_ Encroachment doc___ <br />