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f 40/23/2007 TUE 16: 10' FAX 2094683433 SJC EHD 0002/002 <br /> U <br /> Sale Joaquin County <br /> EEnvironmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> llliltl�Ga TION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd ;f•�_ <br /> Well Permit Application <br /> ,, UNi°T1V <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 appticatiot lj,,Madg irk toritpfiance'wiih San <br /> Joaquin Courtly Development Titte,Chapter&1115.3 and tha Standards of San Joaquin County Environmental Health Department.',I .. <br /> WELL Locatlon�F, La Dist Aw. Cross Street - 5* r„�n�r Assessors <br /> �...�„City f� ZIA�3o_Parcet#�Z�-r� <br /> PROPER <br /> Owner7A (dUU "Address W/cG <br /> C-51Contractor W "j qivopt <br /> �! City IJJH <br /> 7 Zip_�_0�4Zj Phone#�ZS�Z - ] <br /> 1a. Address D 1 CilyRb VIAzip 71 Ur#71Du1 Ph. 07- �Ov, <br /> Consultant/Sub Crrtr von Addres CAK181H1 p�.�f f To C4 A��JC,¢gjG$Z Phone# 53o G !�2�7 <br /> GIS Coordinates:X Y Township Ran e <br /> 9 Section <br /> MRK PERF D: <br /> 0 NEW WELLI BORING (CPT,GEOPROBE,HYDROPUNCH,NANO-AUGER,OTHER`) `15`DESTRUCTION <br /> 0 SOIL BORING# (choose tyke below) <br /> 0 WELL# '8EVER-BORE. DIAMETER_&L ' <br /> 0.Other 0 PRESSURE GROUT <br /> COMMENTS' GROUT SPECIFICATIONS <br /> TYPE OF WELLINSTALLATION TYPE C N TR CTION SPECIFICATI NS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE IUtr p MULTIPLE CASINGS 0 MULTI-LEVEL 1n1ELL CASING DIA:_y_f l <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSTY E OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT: ��$u TREMIE TYPE TO 8E USED: 0 AUGERS �]HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes No (NOTE:MAXIMUM FREEtFALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS-)��_ - <br /> 0 OTHER: t1 OTHER APPROX.BORING DEPTH c-2Y t 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In <br /> COMMENTS; 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 Ordinances,Rules and Regulations,and all applicable California S �1 State Laws. <br /> Signed, Tftie/Company�� ` i , 64"LS <br /> Print Name 5cb Ui Fn vi%.�.ottwh1 <br /> ✓�lrMr <br /> � <br /> Date 0`� + <br /> DEPARTMENT USE ONLY ' <br /> SITE MAP IN UNIT IV FILE,VDIJESS: <br /> WORK PLAN DATED: 9 I D i <br /> Application Accepted By�(t.fAA_ACn, Date Issued__ l e �z 6 Area <br /> Grout Inspection By Dale Final Inspecllon By J Ddte <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS: i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE'. PERMIT/SERVICE REQUEST# INVOICE <br /> �Sp2 �Sp..Da t3i54Z ln.( lvz3�a�-- SR# 5i�.3,�,�p ► <br /> C-57 WCC WAIVER_,,, C-57 Letter of Authorization to sign permit`Encroachment doc� <br /> ELID 2902-00t l' <br /> 6/22/04 <br />