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t <br />San Joaquin County W L� `� �V1 L Fn <br />1i <br />Environmental Health Department SITE <br />600 East Main Street, Stockton, CA 95202-3029 MAR 2 6 2tVHTIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ENVIRONMENT HEALYIT IV <br />Well Permit Application PERMIT/SER <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 />f' Assessors <br />WELLLocation2-7-r715� <br />rl17 L4vy kVt70trt w Cross Street L• � City Zip 117 Parcel# -0Sb <br />PRO�RT/Y�4 $ �ZAro4 R <br />C-57 <br />Consultant / <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # <br />0 WELL # <br />0 `Other <br />Y <br />lJ W'09rVaV-- f'. City Zip qZCPhone* ?Eq `> —O 1 t 4 <br />WG; am 6 � Citjae Ville Zi lob ic# f4g�Phone# U040- I iq� <br />1'�' ' <br />ress� WtUJP1�4Dr� 5CityLu 1 Y64"Licc# Phone 1k ""z1-fV <br />Township I <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />COMMENTS: M1 _'� tvt4 clotP , (n)= 1�$ f"" (-jee- eAti� <br />Range E Section ZZ <br />MW -S <br />DESTRUCTION (choose typ below) <br />OVER -BORE. DIAMETER - Zvi <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 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 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 <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 />Countyrdinanc s, R les and Regulations, and all applicable California State Laws. <br />Signed x 7N I A Title/Company j b- CIAWeL&af <br />Print NameE � Vj Lt�I�.I L {� Date I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />COMMENTS / CONDITION <br />Date <br />Date L <br />Date Issued O Area 3 L X : <br />Final Inspection By Date -r 'I y' <br />0� <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATEREQUEST # <br />INVOICE <br />3SA•oc-7 <br />o <br />.� <br />C-57,/ WCV -WAIVER_ C-57 Letter of Authorization to sign permit Encr6achment doct <br />EHD 29-02-001 WEB <br />9/11/2007 <br />