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11-11 U v LL-IBJ <br /> >a 49 �4 San Joaquin County 4 R <br /> 1 0 4 2008- <br /> Environmental Health Department SITE <br /> { 600 East Main Street, Stockton, CA 95202-3024NVIROMMEN( NEA,#ITIGATION <br /> ` (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orgP�5M""SERVICE UNIT IV <br /> P <br /> 0 Well Permit Application <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 /> 2 Assessors <br /> WELL Location 3yy (40 r ? 0a ck Cross Street N. i3¢ck4yun rICity Zip Parcel# Oy 1 — of- -13 <br /> PROPERTY <br /> Owner Valley ?e�vcde` Address 1KK wo-5} c;rcIt City soot-kfm ZipjS Phone# 17q "S LII Z <br /> C-57 Contractor V`Q,.W D r'\\"r c Address a o 7C 9 7 0 City Lo , Zip 152 Yj Lic#I Zo 1 o Phone# 3(c'I <br /> Consultant/Sub Cntr (J-rovr d -Leio Ana 1*1 Wdress tl I H /IRu-h S4. City Sc a I011\ Lic#PG 57023 Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> -KNELL# MU) q- M UJ 1 0 PRESSURE GROUT <br /> �]*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING rOLLOW STEM DIA.OF BOREHOLE0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 _AIR HAMMER/DRIVEN CASING THICKNESS S cln. �0 TYPE OF CASING: 0 STEEL ;RPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL qif r TREMIE TYPE TO BE USED: AAUGERS 0 HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> >OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH to S BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: WP—kk% (,c.ree0 06 w:--(n 0.0-z o " Cu5%" �ruw. Soy �o to S � 4,0(0-1 <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 Starte�La/ws. L <br /> Signed x Title/Company S�A1'ry�a�0 y 13 I ��/�e✓r�d 2 e�a <br /> Print Name Joe. V q t Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �' D f ► l/�c ,i <br /> WORK PLAN DATED: 2 'Z-o 0-) TZ <br /> Application Accepted BDate Issued /Ag 0�- Area g�7 <br /> Grout Inspection ByL��cAA CY^ Date i <( Final Inspection By (�( A,�,,, Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit✓Encroachment doc_ <br /> EIM 29-02-001 WEB <br /> 9/11/2007 FILE COPY <br />