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San Joaquin County <br /> iEnvironmental Health Departmen SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 � � �I �TIGATION <br /> Q fr (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/chd L� UNIT IV <br /> Well Permit Application JUN 0 5 200 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS <br /> pRpNMENT HEALTH <br /> Application Ishereby made to San Joaquin County for a permit to construct and/or install the work describEPERM psRrUado in compliance with San <br /> Joaquin CounTy+evelopment Title Cha ter 9-1115.3 and the Standards of San Joaquin County Environmental Hea epaiittrrNN��rrKK - <br /> 'Rt' qh p ;40 QO (3ioc)t Is�,�prq�lo .y / l qC�n/ Assessors n <br /> W LL LoLratidR-��"� ross Street z!/,City S/P bi / vY3 Zip Parcel NF1 <br /> 1 <br /> P TY o• r111111 209 - 93 '7 - 8411( <br /> a a YY Address City Zip�r hone# �` <br /> GI ! ° c-s�iF-�� ctor_ `F ' . Ad `�"S r 4lihPs - yVA Li <br /> - S-/ <br /> VF <br /> .��enve- F#F'(r Ad ss _ , pCit ip t i Li hon <br /> -nLy-6'resultant / Sub Cntr�ryyr/trh BEY. �+K, Address <br /> ry5 , � O, "V 'L�' Cityf2nr� v,//comic# Phone#(q1 ' .38 - <br /> / GIS Coordinates: X Y . <br /> Township Range Section <br /> WORK TO BE PERFORMED. <br /> Q NEW WALL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") g DESTRUCTION (choose type below) <br /> (SOIL BORING # FILE COPY Q OVER-BORE. DIAMETER <br /> 0 WELL #. Q PRESSURE GROUT <br /> n "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 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL flPVC BOTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/ OZONE XPUSH POINT (GP or q�P GROUT SEAL PUMPED: Q Yes Q No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0SOIL BORING QHAND AUGER GROUT SPECIFICATIONS C• eift !e�at/je + tutr ' <br /> D OTHER: B OTHER APPROX. BORING DEPTH / 9 S /�. 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 A Title/Company �+-✓I �'h �Ir,F /G � <br /> � �le_N / r f <br /> Print Name .mit "eems�, Date 4 r O <br /> T— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 9000 6 [ oe el S . EI Dorado rhl ' - <br /> WORK PLAN DATED:_ j2 115' ) L) <br /> Apo°cat"c7 4.ceoted By� _ Date Issued J Un e 8 2 00 Area ) <br /> acct �sceuion B y! a $$mGlJF�h§ ln Date 10 ' 7-,r ' 07 <br /> Y r�)374 l'A to - 1 b Final Inspection By Jjr <br /> on Inspection By Date p <br /> COMMENTS / CONDITIONS: Twn CPT <br /> - F�3�NTINO ONLY: AID# FAG# _J <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 35 bl a 9 ,Od 374 DD 0042895 SR# S 08% 9Z <br /> '7_ WC -WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> - - -:2-001web <br />