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San Joaquin County F11 F_WfiPYG <br /> o% Environmental Health B=rPartm SITE <br /> " { 600 East Main Street, Stockton, CA 95202-31� 'V(_ D ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd �� <br /> UNIT IV <br /> Well Permit Application APF - 9 2008 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT9155bWV v'Et';r HEA,1Th <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work des L .('IrnsiaAP'w 65' 's 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 /> ,1 k�/ � Vrl Assessors <br /> WELL Locationb '51XOFtVES%fjr'aN,(n11AO/N Cross Street iv 6k)f4y /�E City (46( Zip VV5_31_ Parcel# O�/'Z7-dZB <br /> T voPF' urt� �eU. c L,7W7, Racv) <br /> PROP RTY <br /> Ownert/Nrla/vacii= 'ole Raao 6/1 A'd" ress (5,j3 QV 87-H urv' E6r City iSTo (/6ro O Zip gZ66 Phone# l G / `�VZ-6.333 <br /> C-57 Contractor ieS l Pell I-)fV6 j Address Z2,0 IV•OFig57.S-Ierlq—City[^' '�� <br /> IV ''2Zip'7S77�ic#�J4-- Phone#530 6Q?ZY L`f <br /> yy�� ��i����� cSUd�"�Z/u n <br /> Consultant/Sub Cnttrr 5./716- Address,-2&6 <br /> ddresss, i 6 WA ITAVE City,,&eAv VIULic# Phone#yE'y/ 7r/JZXY <br /> ,J <br /> GIS Coordinates:X __�• 7� ,I—k?-1 - l g0 Township Range `'/ Section <br /> WORK TO BE PERFORMED: <br /> ') EW W)ELL/ BORING (CPT, HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> ,*SOIL BORING# 5B-!c>C) O9✓aub`S y 549-65 //[]OVER-BORE. DIAMETER <br /> 0 WELL# RESSURE GROUT <br /> a`Other / R UT SPECIFICATIONS <br /> J <br /> COMMENTS: {j��7�V�,t?U/ �k r</1/L�; o;, �J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> 0 MONITORING []HOLLOW STEM DIA.OF BOREHOLE12S�/[]MULTIPLE CASINGS A <br /> []MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS IVl 2TYPE OF CASING: 0 STEEL []PVC 0 OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL ;V TREMIE TYPE TO BE USED: a AUGERS ',OSE <br /> AIR SPARGE/OZONEUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes '�lo (NOTE: MAXIMUM FREE-FALL DEPTH' S 30') <br /> SOIL BORING ��[]'H`AND AUGER GROUT SPECIFICATIONS <br /> /Jp_THER:W �i'm��Q. ; 0 OTHER APPROX.BORING DEPTH '3 0' []BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C NDUCTOR CASING PROPOSED <br /> iA/ � (if YES,list specifications in comment section) <br /> COMMENTS: 1':U ()g iV� _ WILL Vff- 4611PU1? w� fi IJ UNbit;'l] ( IA <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 Ordin ces, Rules nd Re lations, and all applicable California State Laws. -� <br /> Signed Title/Company ell.jcC'1 NVIt2i N" tUM( CIEtJ1-16T �14I(' <br /> Print Name 1�(� p�( S1 t.v� Date 1114 <br /> U / <br /> DEPARTMENT USE ONLYT <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: c) / Q <br /> Application Accepted By Date Issued �' S ' Area 6 O <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 C # ' REC'D BY DATE PERMIT/SERVICE REpQUEST# INVOICE <br /> 71U (p iLf e S R# <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc Qytla--� <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />