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:'an Joaquin County FILE'`� Y <br /> Environmental Health Departm �CE�y <br /> E. SITE <br /> 600 E. Main Street, Stockton, CA 95202-30 �� L� ITIGATION <br /> '��07 (209)468-3449 Fax: (209)468-3433 Web: wvvw.sjgov.org/ehd UNIT IV <br /> rig0,11,t RNfIi�:ALTki Well Permit Application <br /> ��Jr 0 ? 2007 <br /> rrr r; �/h <br /> ?ITISERVI Ef NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS I/ NIAAEN i ¢f Tfl <br /> q7 - �; <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. thl�application is made in compliance with San <br /> Joaquin County Development Title.Chapter 9-1115'i and the Standards of San Joaquin County Environmental Health Department. <br /> �- W//140A/Cross <br /> / /rd� _Assessors <br /> WELL Location �TVV W/�7 Cross Street Tt _City zipy ,?C�: Parcel# 11 <br /> PROPERTY <br /> Owner <br /> J-�1 Fs<c ^•'c ��r City CiMty <br /> .-/1�0C- am;/�IAl= ZZiip, S1 i(-"- Phone'# C,,'- <br /> i4- ax., 1T� N <br /> Address <br /> C-57Contractor G!c u, Ds Address p Lic# Phon�e#f�72 ' <br /> '' <br /> ji jx'(70 <br /> Consultant/Sub Cntr 6lat- f_ -jr IAddress /y 35 11 .'Je'<< Aa.-. City ho, ',k Lic# Phone#C�`! �1� C]'ro <br /> GIS Coordinates:X 5-�,`/'S <'�=;(:�l ,Y 12-1•.L-f/C,; 1.`% Township--F2-1'4 Range Section 3o <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> -XWELL# VE 4 V i E, a AS 1_ tti. .: A-- 4 0 PRESSURE GROUT <br /> [I*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 'HOLLOW STEM DIA.OF BOREHOLE �J MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS D, I S`l TYPE OF CASING: 0 STEEL $PVC 0 OTHER: <br /> AVAPOR��, 0 MUD ROTARY DEPTH OF GROUT SEAL Sc'e c. r t:.,TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 4RAIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> J 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS cx`• I I*V <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH J.c. P;-iic-L x.:50 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> C A CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS' )�'C_ AJ4-,,L '[, A \A/e-,jI V •�.�.r�lV•' Ey SF/t�G: � J�rI�L�I-.� �. �E ..0 <br /> J <br /> L v c: 4— <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 Ordinances, Rules and Regulations, and all applicable California State Laws. v� /� <br /> Signed x ►`� r�� Title/Company eo'j rV\A'At-o' PYv0VL <br /> Print Name PlbkE LT KJ <br /> ��--�( Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD R S: / AJ. j 4)1 <br /> WORK PLAN DATED: – Q — Q <br /> Application Accepted By Date Issued 6 'L s '� Area <br /> Grout Inspection By ate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE�I�NF/O AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35�� UV a l `l9 p <br /> SF;# <br /> C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N <br /> EHD 29-02-001 web <br /> 6/22/04 <br />