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',,,'an Joaquin County `..� <br /> FILE COPY <br /> Environmental Health'Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95N2i1 TIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.orM E1E�j'' �TjUNIT IV <br /> QR Well Permit Application FEB 2 p 2007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 11 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ <br /> R <br /> compliance with San <br /> 'i' <br /> Joaquin County Deveelopment Title, Chapter 9-111151.,3 and the Standards of San Joaquin County Environmen�a <br /> WELL Location�7 /� Ltd i��r^ !1`� Cross Street . ��rder O Assessors <br /> F S City Zip� Y Parcel# /S3-Zso•-ate <br /> PROPERTYI) �,�//��-� � �y / <br /> Owner 7D /" ILe- 1r,rrQS�i2anyAddress Orlec'�+�"'�/ $It e tahaY�la City 6-AKc'Sc..zip �I4,SPhone# ���5�;`t7-3SZO <br /> C-57 Contractor��44 �►�.(t/r 54,krn Address t s0//00-9- aJ- CityM4r-•,`K e Z-Zip yr Lic# S/�SPhone# <br /> Consultant Sub Cntr P-4t)e5t, L• dress Ad t ( K� fir, CityWcnvl ereelCic# Phone#/� �9-0g5s— <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,�011 ,HYDROPUNCH, HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> OIL BORING# Q OVER-BORE. DIAMETER <br /> ❑WELL# U PRESSURE GROUT <br /> a*Other cr GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING o HOLLOW STEM DIA.OF BOREHOLEf4_ <br /> MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL 0 PVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS HOSE <br /> a AIR SPARGE/OZONE,USH POIN (GP CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> COIL BORING 0 HAND AUG GROUT SPECIFICATIONS <br /> OTHER:_0 OTHER APPROX.BORING DEPTH 20 0 BOLTED TRAFFIC BOX or <br /> a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x f�/�`—� f %U/ Title/Company l ko -tJet <br /> Print Name_ �LC�-\ 1-CFS Date <br /> DEPARTMENT <br /> � USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: z35?6 6-. � - 2�SO I✓ <br /> WORK PLAN DATED: Z6�D <br /> Application Accepted By '1 Date Issued 2� 0 Arrea <br /> y Z 4) <br /> Grout Inspection By Date - 71inal Inspection GO Date tP_Z0_6 <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 I SERVICE REQUEST# INVOICE <br /> 0cf / SR# 00 $00 <br /> C-57--V' WC_-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />