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rs + San Joaquin County G r;, <br /> �. Environmental Health Department CS� E <br /> 600 E. Main Street, Stockton, CA 95202-30295 �8 GATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web : www.sjgov.org/ehd <br /> JUN D NIT IV <br /> l Well Permit Application ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <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 /> WELL Location 3/oS S .. E7L 00i140 a Sf c� / 1 Assessors <br /> .cross street city .-J �of 4 horizip Parcel# <br /> PROPERTY 1 ` CC ` "l"l � � ' 1 y I L5y .� / <br /> X Owner CL u`n t � 4-II � �Y Address \-1 l'r� Gc` Cit �5 � �W Zip - l ' o Phone# ZO � � � « rZS.r�I <br /> r y a w 5 /na t: 0r-05X8 3 / 3 5 ma <br /> C-57 Contractor D/'i7LL7/UG Address [Y CityipLic# ' Phone# <br /> consultant / Sub Cntrroi vy4 eel'iHc .FCAddress p 0. 130,X Z45B Cityl/aw � <br /> y,//PLic# Phone#� 38 _ / `x'63 <br /> GIs Coordinates: X , YT <br /> , Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW 7LL / BORING (CPT, GEoPROBE, HYDROP FJ H ALLI QQQE$ Q��E�,FFFjjj DESTRUCTION choose type below <br /> SOIL BORING # � I �1 n ) OVER-BORE. DIAMETER ) <br /> Q WELL # L ,v` U 0 PRESSURE GROUT <br /> Q *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - <br /> Q MONITORING Q HOLLOW STEM DIA. OF BOREHOLE_ Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/ OZONE PUSH POINT (GP- CPT) GROUT SEAL PUMPED: Q Yes Q No (NOTE• MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Ce ea7t ji ew fuyi '& <br /> Q OTHER: Q OTHER APPROX. BORING DEPTH / ;ZS F/, Q BOLTED TRAFFIC BOX or Q 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 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 State Laws. <br /> Signed x11.. - Title/Company (* <br /> x- Print Namer� �` an LT i„e e&: Date <br /> DEPARTMENT USE ONLY IF <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 310 5 S . E I 17 O ra O <br /> WORK PLAN DATED : 12= f 16 ) O to <br /> Application Accepted By 1VI. r✓"r'n rid L McCar -�n e9 Date Issued .jun 007 Area 145q <br /> Grout Inspection By ViA iria 02(� r Date / O - Zz . 0, Final Inspection By Date / A 2.r 'a <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: e <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 35a / E9. o0 374. oo 004289 SR# 0 508 <br /> 3663 2ssoo0 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> BUD 29-02-001 web <br /> 6/22/04 <br />