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� COPY <br /> San Joaquin County f 1`��L ^� <br /> Environmental Health Department tsts i 2007 SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 �I�I�ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eb�VIRJNMt-IVT t1tPi�4�t`T IV <br /> pERI;,aIT1SERViC <br /> c,�otx ` Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> Assessors <br /> WELL Location 17 1 5D LIle Ni wl-D Cross Street f�if� I� City T2g<--� Zip ` 76 Parcel# Z r l'110� 1� <br /> c OPERTY6ro1.eA�'.5TL)"`��,►, hone# 2-�'�1'`d36-''t6o0 <br /> d�,; YY1�S, Gl-1dC Address i'7 q.Sb ll rrl v-y__Z� City -Cq WPB{ ZiP �jUM <br /> C-57 Contractor 0(j,t.J iJP-r�L Address i QZCS r` LI t rte. City I`tU Zip 2Sj4/Lic# Phone# <br /> Consultant/Sub Cnlr Address City Lic# Phone# <br /> GIS Coordinates:X�1T..1; g 3 Y 3 7°7` .- t ,Township Tc-g Range �L4 6 Section 3`1 <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# ?1-?Ii 0 OVER-BORE. DIAMETER <br /> WELL#, <br /> 0 PRESSURE GROUT <br /> 0 Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE &" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:±JA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:QIA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL '-O G} TREMIE TYPE TO BE USED: fAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> II SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS :L/ZF '+ C.=.--a^�Zh <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 20 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ,t IA (if YES,list specifications in comment section) <br /> COMMENTS: p9�NG.S 'Co OE t%D fYrTER- Sot + L V,h An-� G3-thv.�G\ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Pples pd Regulations,and all applicable California State Laws. <br /> Signed. " Title/Company !�Nv ✓!'IRT //'NJS[-� OL/✓c <br /> Print NamDate 1017-07 <br /> DEPARTMENT USE ONLY Zq,65 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: SO W <br /> WORK PLAN DATED: ( /n�'' �([ <br /> Application Accepted By Date Issued �� ' Y:: Area W o 7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# __ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVI � 1 <br /> yq0 �1,� 22-1 wit <br /> °Ig SR#��c236� <br /> C-57_ WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment <br /> aC <br /> EHD 29-02-001 ENVIRONIOENl HULTH <br /> 6/22/04 PERMIT;SERVICES <br />