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San Joaquin County <br />Environmental Health DepartmentUiI SITE <br />600 E. Main Street, Stockton, CA 95202-3029 1VIITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehMAR 1 7 2008 UNIT IV <br />Well Permit Application ENVIRQN10ENT HEAIJ1 , <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ERPJ1T/SFFj'tflj 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 Location 2122 3 A A,rp rf 11 14 jole-4 ii4h Cross Street a}= Slv«t City 3koo,L4w Zip 952ou Parcel# lia`1-1u2- bl <br />PROPERTY J1 <br />Owner t }-tief S4ydc.6-Addresq I Uoye do- City sibconn Zip 9V&z. Phone# <br />C-57 Contractor /b- untk ai m� �vbmA In Address E37 4har�� React City .g�rrkM✓► Zip 9S2 iS Lic# 2l Phone# 2� �i - 4cr It elo <br />Consultant/ Sub ddress 13.7 .aha ry K60d City3fW_Lic# � 0��1 Phone# Z7-4tj -► - i()0ir� <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />-NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />SOIL BORING # I"-)- a OVER -BORE. DIAMETER <br />a WELL # a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2,2 - <br />WORK <br />,2 - <br />WORK PLAN DATED: 1-2, ( 2 d o 1— <br />Application Accepted By oma- Date Issued 3 1 IK osi Area <br />Grout Inspection By Date `i `l c, R Final Inspection By M-ts= c Date It O <br />Destruction Inspection By Date <br />COMMENTS/CON <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />REC'D BY <br />a MONITORING <br />0 HOLLOW STEM DIA. OF BOREHOLE J,'2f a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />INVOICE <br />a EXTRACTION <br />a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br />z6��9 <br />a VAPOR <br />a MUD ROTARY DEPTH OF GROUT SEAL 5C' TREMIE TYPE TO BE USED: GAUGERS a HOSE <br />SR# S 3�3 5 <br />a AIR SPARGE/ OZONE <br />jk1PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING <br />a HAND AUGER GROUT SPECIFICATIONSIZAVe J0 WeaJ eirnert+ <br />a OTHER: <br />a OTHER APPROX. BORING DEPTHBOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED N0 (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE <br />BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I ha prepared this application and that the work will be done in accordance with San Joaquin <br />County Or#iaance <br />Rule nn IReg lations, and all applicable California State Laws. <br />/ -1 <br />&Yt"ham (" C <br />Signed x <br />✓ Title/Company V lJ I <br />�O <br />F <br />Print Name <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2,2 - <br />WORK <br />,2 - <br />WORK PLAN DATED: 1-2, ( 2 d o 1— <br />Application Accepted By oma- Date Issued 3 1 IK osi Area <br />Grout Inspection By Date `i `l c, R Final Inspection By M-ts= c Date It O <br />Destruction Inspection By Date <br />COMMENTS/CON <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT I SERVICE REQUEST # <br />INVOICE <br />3 so I <br />O aj <br />-V-b1 o <br />2ft OG <br />z6��9 <br />SR# S 3�3 5 <br />C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001web <br />6/22/04 <br />