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o�c U 1n, San Joaquin County <br /> �� SITE <br /> Envi.onmental Health Departm ff(( � <br /> 600 E. Main Street, Stockton,CA 95202-30 �V� E� U E[IITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/g(�¢ 2 g 2009 UNIT IV <br /> Well Permit Application <br /> a <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE S'Y ENT HEALTH <br /> YRiT/SEVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app ication 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 /> ./'4:k"% I 1 Assessors <br /> WELL Location 2-1600 y Cross Street I jLc— City /7 �� Zip Parcel# /Z 9-/�,q —Z'/ <br /> PROPERTY �1JfyC, Lc,54y, ?0 742 J ` �2� <br /> Ownertn Nk, b'],9iy,c.. Address City [r rt Ga^'�� Zip 6Phone# <br /> C-57 Contractor�'FNryQ/A rf t S�hc',�// Address�� 1(a ���'UDCity 5'1' '�" zip Clic#,/�7'1Phone# Z6? <br /> Consultant/Sub Cntr Tv0 t,/�ti'//�/4 �Q�Atress ?12 `" City 4 Lic# Phone# y�J y�� -5�'J v <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) /*ESTRUCTION (choose type below) <br /> II SOIL BORT G# OVER-BORE. DIAMETER <br /> 0 WELL# `t X4 SIAi1 t Y�1�-�� 44 k/ 2- AXk RESSUREGROUT <br /> 0*Other GROUT SPECIFICATIONS -+ / <br /> COMMENTS: ,b e!si!rurri( C'k , s l x- 0 PZcuvtes C--Ib( , P-102, e--fci fo�—10 Lfjp��D�rl�-�D,b <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BO CCESS AGREEMENT OR ENCROACHMENT PERAAgA <br /> 48 WORKING HOURS OTICE REQUIRED FOR INSPECTIONS. 7:ro—O <br /> I hereby certify that 1 have p ared this application and that the work will be done in accordance with San Joaq <br /> County Or di s, Rul and Regulations,and applicable California St a Laws. <br /> Signed x // c' Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> Sodom <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2`t too LA 7 .S-kt-fn 2.4 • `-{ t (-f S fr i, <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Are <br /> Grout Inspection By (A Date 2 o 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 1 SERVICE REQUEST# INVOICE <br /> 2�to1 datov 11 ,5 4 o SR# S SZ B �S <br /> C-57.Lz WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EIID 29-02-001web <br /> 6/22/04 <br />