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10 pQU(Ny San Joaquin CountyC)E <br /> z � � .,:2� Environmental Health Department �SITE <br /> CA 95202-3029 <br /> ..,•1 600 E. Main Street, Stockton, JUAJ IVI IGATION <br /> J 209 468-3449 Fax: 209 468-3433 Web: www.s ov.or /ehd © ? J UNIT IV <br /> i ) ( ) Jg 11I Z60 <br /> Well Permit Application O N1wc.,v1 h,EA <br /> NON-REFUNDABLE PERMIT EXPIRES 11 YEAR FROM DATE ISSUED�'4��1T�SERIh ES'iq <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 /> IVD Assessors <br /> WELL Location 21 boo Wes-f i4w,14 Cross Street N A City_ - Zip 45-206 Parcel# 17,11q,050 <br /> (Vic_-I-a r <br /> PROPERTY <br /> OwnerVj:i fforja, /_:T_ Jan &FnSAddress PO aoXr-817n 1 Cit y He'lf Zip Phone# p <br /> C-57 Contracto b�Con Su /17f s Address 311 6410'1441 W 641 D 1741Al e. City We-5'r 6q Lic# 410�D Z1 Phone#Q/6'31I")69 0 <br /> Consultant/Sub CntrHrr_A--r-,it,s Address Z-"I CO3"v'%erCe_ 6e- City�v,)Crd Lic# Phone#115'6&S"6300 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL I BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> `-SOIL BORING# I []OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: GEOTE�C,u J LCA-t_ T—:F57- 6012-J IGS GkoWreb (k PON C0/KP1-J=E7'!1)',j , 0 W E'[j_S. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Stt 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC []OTHER: <br /> 0 VAPOR XM <br /> MLID 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: XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS AeQfi Ge✓K ep f <br /> 0 OTHER: []OTHER APPROX. BORING DEPTH 20 -- 100 Tf 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 4L— 07-4EF LbLitJ/ Cf4L. /5SOAINGS 690(.(M4 U,iooN L044P4,E_7/0N NO Cd IF" <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 Joaquin <br /> County Ordin ces, Rules and egulations, and all applicable California State Laws. �Eii9//'7 s <br /> Signed x Title/Company, /'1/1 GI�j EAqr, tTK`/��� <br /> 9 _ <br /> Print Name S / 4 u Date (O , — 7 <br /> H <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: Fa_�/y� P, d <br /> Application Accepted By Date IssuedlZ /_07 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> LEACCOUNTING ONLY: AID# FAC# <br /> DES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a I1 � 1670 6P, 11167 sR# <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001web <br />