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I <br /> to Joaquin County S J <br /> It. 7Environmental Health Department SITE <br /> ro a. ql� 600 East Street, Stockton, CA 95202-3029 LITIGATION <br /> l � l APR i r3 � G <br /> (209) 468 -3449 Pax: (209) 468 -3433 Web : www . sjgov. org/ehd UNIT IV <br /> Well Permit Application PERMT/ , L . (, <br /> , : <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 /> � �3oo �K'5 �'� A 1..qyl t.l�• 0h ?S Assessors nI• <br /> WELL Location (y. i' CS✓W !7 Cross Street 0 r City S� Zip �O � Parcel# <br /> PROPERTY- 1 1 / 1_ <br /> Owner C I Vi -Y��'O S-r' c�[.1e�- Address 9 Z S N • 1=.1 _ D pfflie (o, City SfOCI 7Un IZip 74� Phonne# z- - 93rd-- <br /> C-57 Contract ro "[A Sf� TCA Address Z27A 7,'e `6 f,� V CityR glt Aw jp /y�-01 Lic#b2141 Phone# .?ID 3O,7V__, <br /> __, yfy3 <br /> Consultant / Sub Cntr C /eSrua� e r Address229 I'CW ,Ty A4� City k Qic/r Lic# 1 _I Y26 Phone# 510 3e7 / 7 yJ <br /> GIS Coordinates: X Y , Township /— Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL / BORING PT, GEOPROBE, HYDRO UNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING # S •+-/ ( aSl�i —/ r'I ' oV >L gremPolt AILI DOVER-BORE. DIAMETER <br /> 0 WELL # 0 PRESSURE GROUT <br /> 0 *Other GROUT SPECIFICATIONS <br /> COMMENTS : 6ROvrr ATeM WVE5TN4WT\ %0r4 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION ECIFI ATIONS <br /> 11 <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOL Z17044 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: . <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS. TYPE OF CASING: 0 STEEL PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAW_j9 9 V✓ Gl TREMIE TYPE TO BE USED: 0 AUGERS Niles CPING) <br /> 0 AIR SPARGE/ OZONE OPUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes S No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> kSOIL BORING q HAND AUGER GROUT SPECIFICATIONS Aca ryki <br /> 0 OTHER: I OTHER APPROX. BORING DEPTH VN"4 2S l 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> `` t CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> ff77 r <br /> COMMENTS: V AY : r,VS �wvA , ' traA,4 Gly ft'V`Ua (,1MA4V1r ✓- cn%V6c 4ci lye cvi( e(= ,dsb <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 Joaci <br /> County Ordinances/I , Rules and Regulations, and all applicable California State Laws. <br /> Signed x � Title/Company LE •`�` <br /> Print Name 1J1N' ry(4- S 6o 'L ! Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 1 a i <br /> WORK PLAN DATED : 61 z. S 0 a;)� <br /> Application Accepted By Date Issued 2 l7 Area <br /> Grout Inspection By---A A-\-.,�,�. VVI. Date Final Inspection By Date <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 /> as-ot $ 8ator SR# <br /> so zq .00 I5f 6FS N/Z9tb' j y 0JS <br /> C- 57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 WEB <br /> 9/11 /2007 <br />