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ILE <br /> san Joaquin County � D n <br /> Environmental Health Department �� � <br /> 600 East Main Street,Stockton, CA 95202-3029ir ATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.orgle"jYf rry, t'QJ� UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED f f���'/j//00% COS <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 Heafkh Deparlment. <br /> 1&15 1AFA 49 Assessors <br /> WELL Location Y Cross Street Cityr Z ry Zip Parc �W <br /> 44?15 1/IiY�S�;d Tidk.1 d� i 4G✓Fc�l tYl 5--V f S'y!' �O ' <br /> PROPE�TY <br /> Comer 1?° OF5 t1-2',5:�at Address4IZE N. City'<7,ZPrCW Zip S" ZPhone#�E '?37—('"3llg <br /> r� X57 <br /> C-57 Contractor �, r,fd Address_ t1 �L�-t L� City oriD YA Zip`�L�Lic# II0Phore#'7164-/5b 1 t(o`7 <br /> Con9uK&ra/Sub Cntr L----ydtL. 41M. {4,4 AddressA01- 52� Ao4,gy l d�Lia#t'-�CZ7¢7 phone#4716 770 5fff' p <br /> GIS Coordinates:X 0T: t p51 Y 12A.Z81 Township Range Section <br /> WORK TO BE PE'.RFO f-2; <br /> JINEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> X* � 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING `POOLLOW STEM DIA.OF BOREHOLE l7 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION l0 AIR HAMMERIDRIVEN CASING THICKNESS f4H 440 TYPE OF CASING: [1 STEELPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4 t TREMIE TYPE TO BE USED: II AUGERS �iOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:` Yes 0 No (NOTE:MAXIMUM FREE-FALL.DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS�To 10%d 82,Djkg `A tg S ,�r ,tri <br /> 0 OTHER: d OTHER APPROX.BORING DEPTH___60:t 4 __BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> CONeliylEldTs; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4$WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certffy 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 Mate Laws. <br /> Signed r �%' TitietCol <br /> mpany_ 9 <br /> Print Name ! 1 1 C/--,A f 1.- V L-A-(Z4-4 Date T1 , l 0 <br /> DEPARTMENT USE ONLY Lop � #M <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -30C-) So dL4 ' <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> �t Date Issued w " °' y Area <br /> Grout Inspection By Date tF f Final Inspection By -Y D e i G <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> [ACCOUNTING ONLY: Al FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK RECD BY DATE PERMITISERVICE REQUEST* INVOICE <br /> `x' 34• c7b 1 t � r 1 S <br /> C-57 7 WCV-WAZVEi2 C-57 letter of Authorization to sign permit Encraoehment doc <br /> ERD 29-02-001 WEB t <br /> 9/11/2007 <br />