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Wan Joaquin County <br />Environmental Health DepartmentSITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9 CSVNnrIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.o e I 11KItll. Ilk/ <br />Well Permit Application AUG 1 7 2007 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISWRGNMENT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install <br />tall the wok described. �Il f1�3 in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joa uin Coun Environmen a artment. <br />{� L L Assessors <br />WELL Location Z W, NGWjr►1{� W v Cross Street I (tvllw,)jj Dr, City si' rw> Zip y Parcel# <br />PROPERTY NV� ltl � �iN � <br />Owner"U' �W4 Address �13Ff1 (.✓/p�u�►1�}/�Ct. city /Q Zip ccqS�iti/ Phone# <br />C-57 ContractorWludw4� Ili Add)ress55U 4c,1t(A/�' l Cityl ZiplU57r Lic#7/oc)�i Phone#7u7-3711-1134),- <br />Consuttant / Sub Cntr �7'/'d k `, �n/�f0��» w1/ut Address3-' Cllr ?a) l ��/l �i, dit isUCavYt{/�1 �Lic# C'� `� S� 3� Z Phone# 53� (+7 ( 460V <br />GIS Coordinates: X Y <br />,Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # MIM -ii, 111w -I 0 PRESSURE GROUT <br />0 'Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA.OFBOREHOLE-_�L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2' 1 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS %, , q 0 TYPE OF CASING: 0 STEEL )(PVC BOTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ZU TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes I`ZNo (N,OTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS lj-?w cf <br />0 OTHER: tl OTHER APPROX. BORING DEPTH -1401 %BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED /lU (if YES, list specifications in comment section) <br />COMMENTS: <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 Ordinances, Rules and Regulations, and all applicable California State Laws. 1 / <br />Signed x (�L'tJR b � Title/Company _ 19 0 to)j 5 ), STgr� /L i /.' ✓1v X2,1 <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2 - <br />WORK <br />WORK PLAN DATED: b S Ion <br />Application Accepted By In / _ Date Issued- IshZ-it/U ;? Area .67_t g <br />Grout Inspection BDate CI (-L--( for "3- Final Inspection By t ,C1... y- O I Date 9- 1.0 7 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# tqo�! R <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE <br />PERMIT/ SERVICE REQUEST # INVOICE <br />l 350.6 <br />tj - Ljk)- <br />SR# <br />C-57 WC_ -WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ <br />EHD 29-02-001 <br />6/22/04 <br />