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San Joaquin County !�oI� <br /> Environmental Health Department LS l C/ �L- SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 FEB - 4 200PITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> F R Well Permit Application ENVIRONMENT HEALTH <br /> PP 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 /> CoAssessors <br /> WELL Location W 0,W uT 1-- r0 ctj +'J Cross Street City b-r Zip Parcel# — V <br /> [� <br /> PROPERTY^ O f ; Address Z <br /> Owner (,� Z, .C���S� City �C�t Zipj�Z�VPhone# '&9 ���"gyp o�O <br /> t `✓ ��(' 0 Q <br /> C-57 Contractor ��esC�W {� DC*11bre� JSG �p�v`��"���iep City zip 1p Li 4i dne# / ?4' <br /> Consultant/Sub Cntr PeAkE b ,1&IAddress 67CG Wna me<"�—CDIity 4k��Lric# Phone# �—'R-3 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# X2Lk - 0 PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 7I1 <br /> 'VMONITORING HOLLOW STEM DIA.OF BOREHOLE_2= , 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:______ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSS,ck STYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f3a 1 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 91Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS &4J <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 1.6 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ( _J CONDUCTOR CASING PROPOSED S (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 prepare this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules a d gulations, and all applicable California State Laws. <br /> Signed x `t•L/ Title/Company <br /> Print Namew 4 l Ati L�• � Date <br /> DEPA TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 / &4,111+ <br /> WORK PLAN DATED: AA!� ZZ 2007 C L)/�tJ f <br /> [ f� <br /> Application Accepted By Date Issued Z� ��' Are <br /> Grout Inspection By Date Final Inspection By Date L ? 0 <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 /> 2?Lo �3 �° ?o /7x27 o SR#dd Seo <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> ERD 29-02-001 WEB <br /> 9/11/2007 <br />