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San Joaquin County <br />Environmental Health Departm SITE <br />600 E. Main Street, Stockton, CA 95202-30 CIEvl�ILL'/MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.ofj*dl 0 2007 UNIT IV <br />,�-�-=- Well Permit Application �� <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS PVIP"I8411 TSER/SER VICES V HEALTH s ; <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 />WELL <br />WELL Location �/s �le �� SI`. Cross Street �riQ57 Sr City Zip 03 X Parcel# 2-33- 379)-vV <br />PROPEgTY '%� <br />Owner��„fiee Sc4-ol /2;/ Address 475 4WI, LDDC// City rlXtte Zip fSV1 Phone# <br />y� tho76G.5G� <br />C-57 Contractor L GHQ Address 1135-0 0Voj7,cr,1bce City �41-Woya ZipfS7V2 Lic# Phone## <br />Consultant/ Sub Cntr Address202 v,/arvv„ Cityg2.,�Lic# Phone#CZa'f%9f3-c'flc <br />GIS Coordinates: X Y <br />Township Range Section <br />PE CODES <br />WORK TO BE PERFORMED - <br />AMOUNT REMITTED <br />CHECK # <br />0 NEW / BORING (CP , GEOPROBE <br />YDROPUNCH, HAND -AUGER, OTHER') pDESTRUCTION (choose type below) <br />INVOICE <br />fWLL <br />OIL BORING # <br />0 OVER -BORE. DIAMETER <br />g l e <br />ELL # _ <br />0 PRESSURE GROUT <br />, CSR # D D <br />0 "Other <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />�O <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE trPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />;g SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS <br />/ <br />0 OTHER: ,I U44 Of a OTHER e.sl (/ <br />APPROX. BORING DEPTH 3c4W 770 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 OrdinUces, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />ilii ioF' <br />SITE MAP IN UNIT IV FILE, AD <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />Title/Company <br />DEPARTMENT USE ONLY <br />j1,5 67 <br />RXX7 <br />Date <br />Inspection By <br />-Z.01-0 <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/ S EST # <br />INVOICE <br />��o r <br />g l e <br />iso <br />Cw,c, <br />, CSR # D D <br />C-57� WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment —do c� <br />EHD 29-02-001web <br />6/22/04 <br />