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U • • FILE Copy <br /> q San Joaquin County (� 2 <br /> H z Environmental Health Department <br /> a <br /> 600 East Main Street, Stockton, CA 95202-3029 AA'' SITE <br /> 49 Fax: (209)468-3433 Web: www.sjgov.org/ehc"V 0 8 2007 1UN T ION <br /> (209)468-34 <br /> f Well Permit Application ENpVrIRpAI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' cRM1 EIV VICES <br /> TH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describetl. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standard,warts construct <br /> San Joaquin County Environmental Health Department. <br /> WELL Location 'DOp �owc <br /> Cross Street f r City Assessors �3 c <br /> PROPERTY n ZIP S 07 Parcel# 3q ,Owner ti_- ' P- � �S Address //H _-iCaml _ r f <br /> City S-12o6/>`*t Zil) Phone# 09-ti7S-j/6/ <br /> C-57 Contracto 29_N�C_/1(J�Address lZ2s 1..,���J�,/ �J ,�/� p(J ZZ y /`/ /.�0� <br /> Consultant/Sub Cntr <br /> / _CitX 1iPYZ-17L ic## hone#7/y o'r 7'6�v/'U <br /> GISCOOrdinle"sf 0 O �o^,/Zl. /DO e(�1 City $ /t nLic# 77/-00 Phone,* �/S <br /> 9 ,Township�=Range Rbt rl <br /> WORK TO BE PERFORMED: Section <br /> NEW WELL/BORING CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> $SOIL BORING# <br /> 0*Other8 WELL# lrn53 OVER-BORE. DIAMETER <br /> PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> t <br /> TYPE MONITORING <br /> WELL INSTALL_ gT�pN rypE CONSTRUCTION SPECIFICATIONS <br /> (] 0 HOLLOW STEM DIA.OF BOREHOLE " <br /> 0 EXTRACTION —L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 AIR HAMMER/DRIVEN CASING THICKNESS <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL y0'_ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 AIR SBORGE1ING OZONE PUSH POINT�or DEPTH <br /> SEAL PUMPED: 0 Yes ANo (NOTE: MAXIM TREMIE TYPE TIUM O BEUSED: <br /> D PTH IS 30) <br /> .SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ci rijr�f/f �x <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH H6 Osz <br /> ()BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 7c L <br /> G a.± <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi I have epared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi n s, and(Reulations, and all applicable California State Laws. <br /> Signed x <br /> Title/CompanyLrL{— <br /> Print Name <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_ <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued_ <br /> Grout Inspection ByArea <br /> Date Final Inspection By Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1�/ '5B &f SR# <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to signpermit /V <br /> EHD29-o2-001 WEB P _Encroachment doc <br /> 9/11/2007 a d " ¢ X-Aciy <br />