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San Joaquin County 2 <br /> y a Environmental Health Department YITE <br /> 600 East Main Street, Stockton, CA 95202-3029 M��j� IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh�iLii"/ 1 9 2007 UNIT IV <br /> Well Permit Application ENVIRONMENT LTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ERMITISERVICE 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 unty Environ ental Health Department. <br /> n, f ! C Assessors [� <br /> WELL Location lL-'i/_S N Lci!vJ��1GJik+7lc+fe dross StreetG r City]" ZipC �ParcelWZ2� 0 j <br /> PROPERTY- i p,�� <br /> Owner r r A Address 3"'� V a Cit (� Zipg7y{Q�l Phone#�/• ?_?z O,iL/�.b r1�jJ <br /> C-57 Cont to ✓';� JK ?' ddress� ! '6•' 4' tN a itp�'r^ n Zip! Lic#.�5�� hone�t6-^S� - 7( °d/6r� <br /> Consultant/Sub Cntr I I T7 •Addresa2� >. Ci Lic Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> r]NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) []DESTRUCTION (choose type below) <br /> 0 SOIL BORING# []OVER-BORE. DIAMETER <br /> []WELL# / 0 PRESSURE GROUT <br /> -fir"Othe 3 $V,i+r " �V1,44j 10�iL'$d:" G�- GROUT SPECIFICATIONS <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING XHOLLOWSTEM DIA.OF BOREHOLEa I]MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DI4Z___ <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0STEEL PVC 0OTHER: <br /> []VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED: kyees/ f (N/O�TE: MAXUM FREE-FALL DEPTH IS 30') <br /> [].SOIL BO IN13 L []HAND AUGER GROUT SPECIFICATIONS lqV�C!D� l TE: MyL <br /> `OTHER: rC">)+'fB ✓ OTHER APPROX.BORING DEPTH .1z®t []BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _ Y S,list specifcati ns in mment section) <br /> COMMENTS /7 /i/ <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 Ord-;antes, R and a tions,and all applicable California State Laws. <br /> /J <br /> Signed x - Title/Company/ir <br /> Print Name �� y 7 _ ate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Date Issued Area S6 L <br /> If <br /> Grout Inspection By Date Final Inspection By Date La' <br /> Destruction Inspection By Date <br /> ./ . <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> ' PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57—jief-"WC -WAIVER_ C-57 Letter of Authorization to sign permit-Z Encroachment doc <br /> 1-1-11)29-02-001 WEB <br /> 9/11/2007 <br />