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SAN JOAQUIN COUNTY <br /> RECOVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 A� R 14 Q�IGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.siAov.org/ehd IV <br /> ENVIRONMENT VIC��� <br /> WELL PERMIT APPLICATION FERMI <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 /> Assessor's/ J 7U// <br /> Well Location 1501 w. rh,../+e7 w��Cross Street S. F­&SY"d Ave• city 5'x'0�k'��^ Zip 9 b S 2 o Parcel# J (� <br /> Property�/ <br /> Owner 1n ��- 1,c��55 ddress /& r---wk weSi- c;r•#A City S-fvck¢w, Zip 'TS'2ob Phone#'(U'I)�`f8''9y12- <br /> C-57Contractor TElr' Address 11SS•o Mo".ci ?All'— ?I. City Ra­c.ko 6wdev%Lic#1005W Phone(/y6)$Sj-8'010 <br /> Consultant/Sub Cntr L-1-4 Te'ro Address 1114 AAaL.+1 S•1'ete-f- City ES ca Iwo Lic# Phone�Lco j)fr 38"-°1'8-8' <br /> GIS Coordinates:X �.935 ,Y "'��• /d Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#_ S 1.1�� S tr sir S(r y1, S tr r ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS C <br /> COMMENTS: •f �` \ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL S 1 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes PNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ?iSOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Ne a i- Ce vin"_- Uro')�_ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 51 <br /> ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: tor_-IS ckdva .-ted +a 5' w t"-- iPfote pE Cofter> " -N $�iL � Saw /eS. <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable 77, <br /> nru ws r� r <br /> Signed Title/Company v ! 6�P J Z �0 �`�"I - <br /> Print Name tJ iZ F Date 4 � <br /> DEPARTMENT USE ONLY vr•�3 <br /> SITE MAP IN UNIT IV FILE,ADDRE S: <br /> WORK PLAN DATED: �� d <br /> APPLICATION ACCEPTED BY DAID AREA <br /> GROUT INSPECTION BY FINAL INSPECTION ® DAT 1 <br /> DESTRUCTION INSPECTION BY DATE 1 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> l�/8� �2 •� •o S_ #OS 3 <br /> C-57 WC -WAIVEP C57 LETTER OF AUTHORIZATION TO SIGN PERMIT tgo ENCROACHMENT DOCOW <br /> EHD 2M1 11/5/07(WEB) WELL PERMIT APP <br />