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QLE COPY <br /> I 7a San Joaquin County <br /> 7 ° Environmental Health Department <br /> K 600 East Main Street, Stockton, CA 95202-3029 IpYNf IGnON <br /> i (209) 468-3449 Fax : (209) 468-3433 Web : www.sjgov .crg/ehd SqN o 1NIT G(J� <br /> dFORN` Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED H k <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 /> Assessors <br /> WELL Location 15`l3` 7 �l. GZ! i/1 MrrG- .er toss Street City SrocK YaJ Zip Parcel#PROP ,t (I,{/ <br /> Owner —Ad'LK -. <br /> G. /� —Ad-. G 7G� City '�, l/ Zi iid0ZPhone# �' 6X <br /> C-57 Contractorl+ 01 Irr)A� 11eC Address SSo 044 //RDfl� City Eloo�. l/ SaT�4 zip(9i_ rVLic# 7 9079Phone# 1-71"'1& , ba <br /> Consultant / Sub Cur_j4-rC- Address /87 Lor ?dLMd City MoDEsr Lic# Phone# S� 2ZZ <br /> GIS Coordinates: X 3S t055 Y —' I2 TSO Township Range Section <br /> WO BE PERFORMED: <br /> 0 NEW WEL I BORING (CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER') DESTRUCTION (choose type below) <br /> --O-SO BORING # ,t 0 OVER-BORE. DIAMETER <br /> U WELL # A/A7ilC ����lD [T. 0 PRESSURE GROUT <br /> O 'Other rl GROUT SPECIFICATIONS <br /> COMMENTS : <br /> TYPE .OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING OLLOW STEM DIA. OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 05 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 305 ) <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS ,, � <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH kaOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES , list specifications in comment section) <br /> COMMENTS : <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 prep e is application and that the work will be done in accordance with San Joaquin <br /> County Ordinancftsj, as a egulations, and all applicable California State Laws. <br /> Signed x Title/Company d/O.fz ./2 —4Fd S � <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDR ff5 6 qr% <br /> WORK PLAN DATED : P - O <br /> Application Accepted By Date Issued Area o <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Dale <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE COPES FEE I FO AMOUNT REMITTED CHECK # REC' D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> oo '4 lo G sOF sR# <br /> C47 WC - WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ // <br /> END 29-02-oat WEB Qo a7C / .�•��� <br /> 9/11 /2007 l� <br />