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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaquin.ca.us/ehd <br />A L <br />D <br />ITIGATION <br />JTZ* <br />0' V <br />�i k_ R t•�}(� <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN " I "" L r 1 <br />PERMIT/SERVICES <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 f <br />WELL Location( � l Gross Street i_r�_City ' r�� Zip Parcel# .z5 <br />PROPERT`�T 1 _ 2 <br />Owner Address . l _._Cityi, v� Zip SYS 7 Phone# ii J `jLI ,� 3 <br />C-57 Contractor00 Address_ L, — I Cityr� ip �I�;- a2la( /Phone# I 1 Li (.`�ji 3j ?33 <br />Consultant / Sub Cntr d Ad#Z2 -�% ity �' k _Phone# 7" <br />GIS Coordinates: X , Y <br />Township <br />Range _ Section <br />ORK TO BE PERFORMED: <br />JXI EW WELL ! BORING (CPT, GEOPROBE, HYDROPUt'*,AND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL PORING # _. _ _ 0 OVER -BORE. DIAMETER <br />WELL #_ OI ,, —) 0 PRESSURE GROUT <br />0 t h a r GROUT SPECIFICATIONS <br />COMMENTS: 17 <br />1 Vy <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER QUEST # INVOICE <br />350 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />7- J SR# v_3g�o® <br />ILI <br />MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />�0 :_XTRACTION <br />0 `AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STFEL XVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEALyTREMIE TYPE TO BE US,: -7D: GLRS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 Yes >IkNo NOTIr: MAXIMUM Fi?`- :+FALL ,�1=PTH IS 30') <br />� <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS i •C le'—'a t <br />0 OTHER: -0 <br />OTHER_ <br />APPROX. 30RING DEPTH_ / S 0 R0LT4D I RAF C BOX or <br />CONDUCTOR CAS NG PROPOSED (if YES, list specifications in con;ment sPCtion) <br />COMMENTS <br />NOTE: OFFSITE EORINGS REQUIRE A"^E,33 AGREEMENT OR ENCROACHMENT PERMITS._ <br />,�3 WORKING HOURS NOTICE RE')UIRED FOR iNSPECTIONS. <br />I hereby certify that I have prepared `his application ,and that the work will be done in accordance with San Joaquin <br />County O ances, Rules and _gqulations, e,nd all applicable California State Law, . <br />Signed x ; l 6' X / /�,'�- Title/Company 1( <br />Print Name A ) C Al R <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /--1 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS / CONDITION <br />DEPAr" I MENT USE ONLY <br />Date Issued <br />Date___ _ Final Inspection By <br />Date <br />Date <br />T' Q Area�� 2� <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER QUEST # INVOICE <br />350 <br />el <br />3�s9 <br />7- J SR# v_3g�o® <br />ILI <br />C-57 ✓ WC ✓-WATVER_ <br />EHD 29-02-001 <br />9/30/2002 <br />C-57 Letter of Authorization to sign permit0 <br />