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,o.P "`"•�o San Joaquin Count' HIMI F COPY <br /> z i t <br /> Ennmental Health De artment <br /> y P , SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 I � I <br /> ��-,LI��/Iffi� Q�,�,IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application `SPR - q 200a <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEBI��I,Ir-'•� N{ 'k'�C 1 <br /> I ii r hEALT <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Wppli4wE Wafi&in compliance with San <br /> Joaquin County Development Title,Chapter 9-111155.3/and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location l�/ �. U/Y( � ��N Cross Streel- %j/ Wy X#67" �./� <br /> Zip Parcel# <br /> PROPERTY f s.vrfEZS/ <br /> Owner RTELC�S �qC' LC(Address 2377C.Q&1-9Yf1WP6(10 City 7rZ,�,�/INCE_ Zip9&'56/ Phone#3/C•k/,P,4?&1/ <br /> C-57Contractor 12iPI CC IN Ei Address 220 N11,��,t/f$T SI�CCT City WL"' ZipgS-92kic#0'233 ] Phone#63�` EC S Zy2'/ <br /> Consultant/Sub Cntr <br /> S1 ��i Address JWy ry147I1jVF `[11' `jf {1Meiif <br /> !J� bc# Phone# 9/4-`/r;7/ Y 7/(� c <br /> GIs Coordinates:X 2C <br /> � T J2 Y-12]. 7D q Township 0Z > Range Section <br /> WORK TO BE PERFORMED: <br /> p WALL/BORING (CPT OPROB DROPUNCH, HAND-AUGER,OTHER*) XfESTRUCTION (choose type below) <br /> `;SOIL BORING# -� h� qV1 �'G []OVER-BORE. DIAMETER <br /> 0 WELL# -ff:�RESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> - up�� T Q <br /> COMMENTS: � O�iri/hS /� % ,/� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLES. a MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS I�/� TYPE OF CASING: []STEEL []PVC []OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL " �S/ TREMIE TYPE TO BE USED: []AUGERS •HOSE <br /> 0 AIR SPARGE/OZONE VUSH POINT(GP or CPT)GROUT SEAL PUMPED: (1 Yes o (_NOTE: MAXIM FREE-FALL DEPTH IS 30') <br /> SOIL BORT G� ,�]HAND AUGER GROUT SPECIFICATIONS k6R C1--'1{� / <br /> MOTHER:W �i�PCP,9�'/(I OTHER APPROX. BORING DEPTH .3S []BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A1114 (if YES,list specifications in comment section) <br /> COMMENTS: IW61)5f"Pd M4y Vc-b ' Wo1 AV^���1�(�G L� Iti�K <br /> b(- i\1 4�,k2 vvt,GA,t Nei, <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 repared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinAeS, es nd R uJlations, and all applicable California State Laws. <br /> Signed x Title/CompanyPO�LCIENVI�tt"1E <br /> Print Name VA ILVA Date 411108 <br /> I� <br /> DEPARTMENT USE ONLY 29, 60 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �Z4�'G�-! <br /> WORK PLAN DATED: ?t9® <br /> Application Accepted By Date Issued �' S 'fl O Area Ob 0 <br /> Grout Inspection By 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 C116-i(ffi v1S'A REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z� l sR# 3�l <br /> C-57 WC -WA EVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />