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e " SAN JOAQUIN COUNTY FCE V EDD <br /> ENVIRONMENTAL HEALTH DEPARTMENTSITE <br /> 600 East Main Street, Stockton, CA 95202-3029 AUG 2 2 20061TIGATION <br /> / Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.s' ov.or "17 <br /> \ IKON ` E U N��IENT NEAL': IT IV <br /> WELL PERMIT APPLICATION PEPUMIPHRVIM <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. Assessor ipII -logo- Z3 <br /> 1 Car.IL II�� T / <br /> Well Location b Gob Cross Street I V ir/1Q/j_ City O d : Zip 9.S24Z Parcel# 011-Mo-Iy <br /> Properly <br /> Owner 5("11,4 <br /> v ,4 .Jr` Address14.�V � 7ci <br /> ty Zip j sly Phone#790-3 d y <br /> j Z <br /> C-57Contactor v 1Teg <br /> AddressZ62s( /•�4dls.oL,� St city a Lic# 91"6 Phone 5 30-Z/4-26 q1Consultant/Sub Cntr K� Address 67-1 Fo U 0-✓4 5/-- City 5� '�{1�Lic# Phone - " .•L(S V <br /> GIS Coordinates:X 62g'( q-L ,Y Z2 15- ,Township l Ciy A) Range St Section 3� <br /> WORK TO BEP ED: <br /> %NEW WELL/ (CPr r PR YDROP ,HAND-AUGER,OTHER`) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#_ 1( ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> ❑*OTHER // // // (�c GROUT SPECIFICATIONS <br /> [1 <br /> COMMENTS: 7 GY.GGonrdP //I.iAy'j K cL D�..o..- 44(o4fn...n_ �GS��?� /rn ( <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z-' 0 MULTIPLE CASINGS C3 MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESSA 4q TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL ,Z­01 TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE [.PUSH POINT OR CPT)_GROUT SEAL PUMPED:❑Yes W No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS AI Get <br /> []OTHER: ❑OTHER: CONDUCT BORING DEPTH _701' ❑BOLTED TRAFFIC in w OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (H YEa,list apectlicatims in mrrvlrent 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 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, d all applicable California Laws. <br /> Signed �T '4e4 ;� C7 <br /> / Title/Company "O-/Ag <br /> Print Name /"t ( 7ti1�rLc `. qc.'..[v A Date t 2 Ile R <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: N 0 7 N, 33,u., <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED B DATE ISS ED Off' AREA gq <br /> GROUT INSPECTION BYFINAL INSPECTION BY oS DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: Pd>elc0' LJS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> d-q6l — lei 107 J4:f- B 0 SR# Or`55-A141 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PEROT ENCROACHMENT DOC <br /> EHD 2MI 11/5187(WEB) Wal.PERMIT APP <br />