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. ...... ....... . . <br /> c- pt Joaquin County <br /> z yf Envirc, �. cental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 IITIGATION !i <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED;%NiIi 0't!'I I_i`c-i 1-3-L}T! <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thisnr app'licatio`n is made in compliance with San <br /> Joaquin County Devel�opme,nit Title,Chapter 9-1115.3 and the Standards of San Joaquin Count Environmental Health Department. <br /> J4Q., 3nY�f� / A� '/- Assessors L <br /> WELL Location mk I✓�a [oc.� 't-e _LM^ROross Streetr�...Kt&-'6^-ity f4�4-cc. Zip q-j�337 . Parcel# Z! y-0ZQ- M <br /> PROPERTY �,C,� - <br /> Owner T',.L: (3c.._�LLL Address 3LF Vis+-O-i7Lr- City LLScIV� Zip 4�7L Phone# <br /> // ee gys.5`3 a0-7 <br /> C-57 Contractor 6� ac T 7 �. Address 15-0 !'fovP �vHl City{lwi'1.,,&Zip &" Lic# L56' Phone# 1xS--543 <br /> Consultant/Sub Cntr�.rc F04c_ICewYA(-ks A�ess ,(,K.i3.�. a"-�/City S--n Lic# Phone# -707-Y33-2JLf <br /> 5e.: 13� <br /> GIS Coordinates:X ,Y ,Township Range - .Section � <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT,GEOPROBE, HYDROPU A AU ER OTHER') p DESTRUCTION (choose type below) <br /> $SOIL BORING# . 0 OVER-BORE. DIAMETER <br /> PRESSURE0 WELL# � V O P Y G ROUT SPEC F COATIONS <br /> 0'Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> . 0 MONITORING _ 0 HOLLOW STEM' DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Nom_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN -CASING THICKNESS PA TYPE OF CASING: 0 STEEL 1]PVC. g OTH� _ <br /> 0 VAPOR - 0 MUD ROTARY • DEPTH OF GROUT SEALrwf.i e TREMIE TYPE TO BE USED: .9 0 HOSE <br /> 0 AIR SPARGE/OZONE $PUSH POINT(GP or CPT)GROUT SEALPUMPED: 0 Yes {"No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ASOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS - �` f/u'^� -T-IRce,�, <br /> 0 OTHER: - a OTHER APPROX.BORING DEPTH /I 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N1�7 (if•YES,list specifications in comment section) <br /> COMMENTS: y <br /> I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1-Rave prepared t plication and that the work will be done in accordance with San Joaquin <br /> County Ordin`an`ceS(Rule, and R4gul ion's, and all applicable California State <br /> Laws. <br /> Signed x � �!� /} ,�i Title/Company 7 C "% �: 1 d tom"Print Name t`l tA-6l�:il ILA"( IRI ( -d \ Date_ i <br /> —� DEPARTMENT USE ONLY t ! <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I l & D W Yn C ernA; it ye-w v e- <br /> WORK PLAN DATED:/ a <br /> Application Accepted BfDate Issued nc ✓J moi✓ 31 ZO07 Area <br /> Grout Inspection By!J>sf/f'�rs�'��� <br /> ' 7�jrA%.'r7��t7 - Date %<"�E '(f � � Final Inspection By `!�'��f,�leea��%E��f�?��Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY:. AID# FAC# / <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 350 99. 00 89. cv 10046 - O-31-0sR# Uos24GS <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB - - <br /> 9/11/2007 - - <br />