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it 1I-p`N o SAN .JOi4QUIN COUNTY <br /> �� ° <br /> zq ENV , . . JNMENTAL HEALTH DEPARTML , 4T � O ITE <br /> I ,r K O � o <br /> 600 East Main Street, Stockton , CA 95202-3029 MI DATION <br /> s. p Telephone: (209) 468-3449 tax: (209) 468-3433 Web: www.sjgoy.orglehd <br /> 4 2009 UNIT IV <br /> 1 <br /> I ENVIRONMENT HEALTH WELL PERMIT APPLICATION <br /> PEROTISERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j 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 , cha pier 9-1115,3 and the Standards of San Joaquin County Environmental Health Department. <br /> / Assessor's <br /> Property <br /> encaptior+1 k1 . Fvc,�...I-(,r,'r..��r� Cross Street Tro(,,4 Old, City Ir&04 Zip Parcel # <br /> Owner 6UV�i/���lf eJCs+ra Address WY517J . il'= i5t. So;kA City TYa �� Zip &93L Phone # ZA <br /> C-57Contractor I✓eb(l6-P_(Af ✓ Address I� GGI6i qII( & eel II-- '' ((-�T city lZr"nrlv )('fl[(�", .va Lic # -t36J31phone �(�6 'G'?/1-- 1�46ViL <br /> Consultaut/Sub Cni�S Address Ib" IAQ TWJC, Oor' 4YP( . City fl D ftWALic # Phone!QALG -/" t l00 <br /> GIS Coordinates: X �� , y yi19 ") J $ , Township us Range RSf SectionI <br /> RK TO BE PERFORMED: <br /> NEW WELIJBORING (CPT, GEOPROBE , HYDROPUNCH, HAND-AUGER. OTHER') ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> WELL # ❑ PRESSURE GROUT <br /> `OTHER Di :,n )/ v GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE3_.rn_.__ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br /> ❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL L PVC ❑ OTHER <br /> VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br /> ❑ AIR SPARGEIOZONE ❑ PUSH POINT (GP OR CPT). GROUT SEAL PUMPED: ❑ Yes El Na (NOTE: MAXIMUM FREE-FALL DEPTH <br /> II -IS 361)+ <br /> O SOIL BORING XHANDAUGER GROUT SPECIFICATIONS I ft/J IC474 6&( O�- LI a rXm�r� iC_�I <br /> El OTHER_ ❑ OTHER: APPROX. BORING DEPTH S ' b )F¢ V BOLTED TRAFFIC BOX OR E) STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (dYE'5, Ilst Wmficalions In wmment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I hav prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, and all licabte Californi ws <br /> Signed Tille/Company C t4 <br /> Print Date 9 /V9 o } <br /> DEPARTMENT USE yONLY T <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S ? E� 6 47 � <br /> WORK PLAN DATED: U <br /> APPLICATION ACCEPTED BY . [ DATE ISSUED AREA <br /> GROUTINSPECTION BY LS FINAL INSPECTION BY DATWO O <br /> DESTRUCTION INSPECTION BY` �. ,Q /J DATE <br /> / <br /> COMMENTSICONDITIONS : (��.)c" LIX /,Id /-m .b Owe-16 4/ YJpygl S <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE COG ES FEE INFO AMT REMITTED ±CH;ECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> e <br /> C57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIG PE IT ENCROACHMENT DOC <br /> EHD29-01 11)5707 (WEB) WELL PERMIT APP <br />