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San Joaquin County <br /> Environmental Health ®epartmen ;;iC'��J c _---- _- <br /> �i� <br /> 600 East Main Street, Stockton, CA 95202-/029 M E TI G A TE 0 <br /> (209)468-3449 Fay:: (209)468-3433 Web: «j�W.sjgo�.org/dtrri;i✓; L1!IY UII <br /> Well Permit Application F., <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEb -? <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 /> Assessors <br /> .AjCS( u:v.;�cZJ�rt�S <br /> WE'LL'Locition ����`� S4�'VC,ta PWA-) Cross Street f�yAV+ o City�vt.�-�Vr1 Zip Parcel# � �Jt" U� ���2 <br /> DN 6�{ G <br /> PROPF�� B `frc,SIF _ r- _�c. l^i U ✓ 5 Ei YJ`'�Zhone# <br /> Owner_ Address p <br /> _ •! �' ZLr L e<<►j-�y' c# Phhbne# q1(P <br /> C-57 Contractor tr�'t kCVV� \C C%- Address !, r DC Ci LL' VY p Lic# <br /> Consultant 1 Sub Cnt4t 1%fjR`CESs 2C','L� City i(9Ci;' Lie# Phone# /F�P�5 I,' V L1 <br /> C��= EYf/ <br /> GIS Coordinates:X Y ,Townships ! 1! Range Section �(4 <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (COPT,GEOPROBE,HYDROPU NCH,HAND-AUGER,OTHER-) u DESTRUCTION (choose type below) <br /> ?Q SOIL BOR111G# 0 OVER-BORE. DIAMETER <br /> WELL# S.G a PRESSURE GROUT <br /> *Other ) C �_ 7� GROUT SPECIFICATIONS <br /> COMMFNTS: g�r-r,n �-a <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING HOLLOW STEM DIA..OF BOP,EHOLEP Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 2�t TYPE OF CASING: 0 STEEL VVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL N L TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE (PUSH POINT(GP orCPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> MOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: W �Y' 0 OTHER APPROX.BORING DEPTH LZ.00 BOLTED TRAFFIC BOX or XSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (�� (if YES,list specifications in comment section) <br /> COMMENTS: <br /> DOTE: 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed - Title/Company 'rFbG'/' <br /> Print Name �%Gl �' ' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Ls cy 0 <br /> WORK PLAN DATED: I l� (`� 0� - <br /> Application Accepted Date Issued 3 Z Area <br /> Grout Inspection By _ �Dale_4.1 JT7312--Final Inspection By Date <br /> Destruction Inspection Date <br /> COMMENTS/CONDITIONS: <br /> FACCOUNTING ONLY: AID# FAC# <br /> ODES FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/7SERVIC�EREQUEST# INVOICE <br /> o � �� sR# <br /> C-57_ WC=WAIVED_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />