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"ECEq Eun RIGIN A L <br />San Joaquin County EP 14 2007 <br />Environmental Health DepartmenSITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA -PPI -NNIEW HWHIMITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov./SER1/IGES UNIT IV <br />�,�/% f ��° Well Permit Application s I, <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED %� ✓�G%L�^ <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 />WELL LocaUonSF 04 9105 11 "1111 (10661VCross Street •/�i- City �I�� Zip bzS ''- Parcel# Assessors <br />61161 <br />PROPERTY <br />Owner <br />C-57 <br />5 Phone# 20 2- %'d_ / ( <br />53v -66s -242y <br />Consultant / Sub Cntr51��SE✓Iw✓u�lAo�-V TW Addre'svrtt/N1� D-, t' SC ,(timet /et��ic#Phone# 531 674- � Z <br />GIS Coordinates: X `� Y —(2-1.3-3(6_, Township n—_ Range L• r Section <br />WORK PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />0 SOIL BORING S 0 OVER -BORE. DIAMETER <br />1[,�NELL # W-1 01 u) -1 0 PRESSURE GROUT <br />0 'Other GROUT SPECIFICATIONS <br />COMMENTS: <br />E 0 MLL INSTALLATION TYPE <br />'JWONITORING HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CP1 <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: n OTHER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: =_, <br />CASING THICKNESS 5 1.qo TYPE OF CASING: 0 STEEL '®,'PVC 0 OTHER: <br />DEPTH OF GROUT SEAL -3' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes`'Oo (NO E: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS ? Cc'n1� <br />APPROX. BORING DEPTH 2-1 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list soeafications 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 OrOlnan cei ules and Regulations, and all applicable California State Laws. <br />Signed x sl.4T+°t I/1 ��/ TitWCompany V 4J, 5 F,,v /I miliQ <br />, fill <br />Print Name Date — 13 -6 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: #3 <br />WORK PLAN DATED: <br />Application Accepted By 4 Date Issued Area Q(� <br />Grout Inspection By Date 0 Final Inspection By <br />Destruction Inspection By Date _.�....r <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: A!D# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECKS REC'D BY DATE <br />PE # INVOICE <br />�; <br />J`;`►�,+ <br />�t ` +� 9.1 <br />n <br />SR# biJ 5Z6 / Co <br />C-57 V11 WC ', -WAIVER_ C-57 Letter of Authorization to sign per�mit-,L Encroach me _ <br />EHD 29-02-001 <br />6/22/04 <br />�o7-6Sv—o 6� <br />V' <br />m <br />`J <br />