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man Joaquin County r I! --- <br />Environmental <br />!-- Environmental Health Department SITE <br />600 East Main Street, Stockton, CA 95202-3029 APR — 1 '010MITIGATION <br />(209) 468-3449 Fax: (209) 468-343? Web: www.sjgov.orgfL�/ehd jjr per,• t" + , t+ r,`, ! Y%1NlT IV <br />I•�'b'�t'it�l�d l4i�l`) i r:..i � . <br />Well Permit Application PE;;f IUT )IPF,Vf,,c" <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 9-1115.1 no the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location _51 1 wpsp Fvtmra rYft f Cross Street y.L•j, L n rjln t City Zip qr;�oy Parcel# 13 7 )!q- io <br />PROPERTY <br />Owner n2vz Address 5ij t,yt,j Frt -rit _tlr,,rF City .3kekf�„ Zip433o3 Phone# vii-y(r,•No�r <br />Cuwr,.rnei- <br />C-57 Contractor Hilehe 1 1) 1111!24 Cnvjitonaninl Address 77et ftq; t p /bens: City z- -eka Zip e3 Lic# Phone# 7c+1- y iy ieVv <br />Consultant/ Sub Cntr p;tuon,avd (Sar,Enrarerniai./,Inc Address 2, 1 �hejw erri City 3fcezfar, Lic# Phone# -,)o,t 9&7 1 <br />GIS Coordinates: X , Y , Township Ra <br />Section <br />WORK TO BE PERFORMED: <br />-g: NEW WELL/ BORING (CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />a: WELL # 08-/, Litt -2. ew 1, Clr; ;2 etom, bw' / 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING HOLLOW STEM DIA. OF BOREHOL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: J" BnIY <br />`'EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNEIS � � ti TYPE OF CASING: 0 STEEL 'RPVC 0 OTHER: <br />'VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f2'b4 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS iup T_/n PcrilCrnd R lUlel firwrrf <br />'OTHER: bbniyahbi 0 OTHER APPROX. BORING DEPTH 3S'h_: 15 'bi: D;BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSEDpj�tl (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. <br />Signed x_ ; :7 <br />Print Name Vc,60 L. 1- <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: A 1101 0'1- Ir <br />Title/Company bite atiiutn+�P,lucmrvd r�rni_nv,rnnmrira:f.ln� <br />DEPARTMENT USE ONLY <br />"..A- l <br />ate ai An✓, I 08 <br />Application Accepted By Date Issued �2 0-b Area <br />r� <br />Grout Inspection By LA-�'.r.— Date `1 o Final Inspection By t _ Date O <br />Destruction Inspection By Date <br />COMMENTS / CONDI <br />b <br />'T <br />4} - <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT I SERVICE REQUEST # <br />INVOICE <br />5-r'A <br />$�,J�7 <br />C-57—v/WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />