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San Joaquin County ORIGINAL <br />Environmental Health Department SITE <br />{ 600 East Main Street, Stockton, CA 95202-3029 D ION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd �="' ` N <br />UNIT IV <br />`+FOR Well Permit Application <br />/ xS <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FN�If�VrJ�IlEiV��TyypiriGEvrpA,eL4TN v/�/ <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This 1d�C11 v I1 �Oiance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health <br />SO Assessors <br />WELL Location �� .� (.J, � /SkT M+t.E ?� Cross Street io /� City S'TQcK %o•�Zip Parcel# <br />PROPERTY ,/ // <br />Owner/,�iEs f�EG GD/ RWDA647'i6CAddress /�%�CJ.yw�/2 City o Zip9s�iz Phone# -�49/�r/ <br />PE CO ES <br />C-57 Contractor Zoo -;',W,4& -h Address City Zip Lic# Phone# <br />AMOUNT REMITTED <br />Consultant / Sub Cntr t4TGSSoC//iiFS Address ///7 LONE t�P[ .N City /1/oS Tc Lic# Phone# S%�ZZZ <br />REC'D BY <br />GIS Coordinates: X3O55 Y—izt.Y57 Township Range Section <br />INVOICE <br />WORK TO BE PERFORMED: <br />/5 <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />R, /0 3 SR �• � <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />B WELL # �`l 0 PRESSURE GROUT <br />1 <br />0 *Other GROUT SPECIFICATIONS <br />�s <br />COMMENTS: i C� t �iXC <br />C!) <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />�+ <br />ONITORING OLLOW STEM DIA. OF BOREHOLE$_4T 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S•CH Y o TYPE OF CASING: 0 STEEL OVC 0 OTHER: <br />1 <br />0 VAPOR Rv1UD ROTARY DEPTH OF GROUT SEALVRAI*$LC TREMIE TYPE TO BE USED: eUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: g'Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS foA-rLA++'b C(�-wdr7' A•BDV('� 96.',70._'l 7 -4C <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH IS— /101 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED YCS (if YES, list specifications in comment section) <br />COMMENTS: SEE L✓ooeKPLAni s✓BSuArAGE Ai. -pc, Jo m Z% o7 <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 prep aedjhis application and that the work will be done in accordance with San Joaquin <br />County Ordinances les an talations, and all applicable California State Laws. <br />Signed x Title/Company ei-Go 4-1>G / S 7` <br />Print Name // o % �i✓r /✓r_ /C Date a 3 a <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: y— /'P-6 <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectio <br />COMMENTS / CONDITIONS: <br />Date Issued_ <br />I Inspection By <br />D <br />ACCOUNTING ONLY: AID# FAC# <br />PE CO ES <br />FEE I FO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE EST # <br />INVOICE <br />3• <br />/5 <br />R, /0 3 SR �• � <br />C-57✓ WC—Z- WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment coc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />