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San Joaquin County <br />° <br />Environmental Health Department SITE <br />600 East Main Street, Stockton, CA 95202-3029 MAY a 7 'VITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/IT <br />e <br />AdVIRONMENT HEAPP IV <br />Well Permit Application PERMIT/SER S <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />y_ I Assessors <br />WELL Location `�TT Cross Street r0 J'' City 1� L I� Zip Parcel# I 15r7 ''Z 6"IPROP�[ <br />OwnerERT /� I � Address I v, ' U l va' �Jt', City �t �` v� Zip t 16;honee#C,2- f --t t7 7y� <br />C-57 Contractor ($VQ �i 1�1%�\Address �d r'�\��i ��ll City uv Zip Lic#4 !� V�Phone. l�7 7 v\" <br />Consultant/ Sub Cntv'� �5d \�`�� Address \11 i.0AL -%ity � Lic# Phone# <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />0 *Other <br />Township <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: _ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLEZ ) 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL P )—<0 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes 0 o (NOTE:: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS r' (I�y0- <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH } �r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 Ornanncce-s,,, Rules and Regulations, and all applicable California State( Laws. <br />Signed x P -�Vim ( -)� Title/Company slob � Q ��U � �� � Ac S Su' 1 (J q� <br />Print Name <br />\ t �r IA\A Von \ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Lfa T!5- idd -I-' <br />WORK PLAN DATED: 1 I I S I e -x- <br />Application Accepted By C-- Date Issued S J( 3�B S Area <br />Grout Inspection By Date S I Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATEREQUEST # <br />INVOICE <br />'� <br />�o <br />f kYl S <br />5" r / SR#0 os <br />ssv <br /># ziK <br />Z3 <br />C-57 WC _ -WAIVER_ C-57 Letter of Authorization to sign per ,Encroachment dock' <br />EI -ID 29-02-001 WEB <br />9/11/2007 <br />