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:0/01/2008 WED 10:48 FAX 2094683433 SJC EHD 2002/002 <br />SAN JOAQUIN COUNTY <br />UC�,Jit - <br />F. yA <br />ENVIRONMENTAL HEALTH DEPARTMEPg(? 3 0 2008 SITE <br />600 East Main Street, Stockton, CA 95202-3029I <br />••.cah...;.A :; j Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: i !�i Wh �IFALTATIGATlON <br />A UNIT IV <br />ti 9Kr% PFRIVIIT/Sl-- ,CCS <br />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 instal( 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 />N oYkk MS -04 S� Assessor's <br />Well Location 316 Cross Street !✓ • �.��� $}. City Loc); Zip ci I D(� Parcel* o ti t -v3 Cr { { <br />Property <br />Owner levy + SQ'$Om f vSSt" Address 123'1 W+ City ZipcIS 2�_Phone# ,01-• 3x--1- 7-345 <br />C-67 Contractor rCA Address butt Cv.7\vl DYCityU.j. Lic#EA q-MRone F>3{ "16k--4- - 80 <br />Pcr <br />Consultant/Sub Cntr E.wu=v ci City so --A i o S� Lic # b t5PhoneLa - 8 51 -- D6' f? <br />GIS Coordinates: X <br />Y Township Range Section <br />WORK TO BE PERFORMED: <br />FEE INFO AMT REMITTED <br />❑ NEW WELUBORING (CPT, <br />GEOPROgE HYDROPUNCH, HAND -AUGER. OTHER-) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />SOIL BORING# <br />9 LS6--1 8 —,A 1 (& - ❑ OVER -BORE DIAMETER <br />❑ WELL# <br />PRESSURE GROUT <br />❑ `OTHER <br />GROUT SPECIFICATIONS <br />{� <br />COMMENTS:l�F�v>Y�C22�^�1Q�e��q V-s+v�u Crete RYat+2 S�ts+D{tKG r��ViC¢ <br />_ <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING <br />❑ HOLLOW STEM DIA. OF BOREHOLE �k 2-" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 1JA <br />❑ EXTRACTION <br />❑ AIR HAMMER/DRIVEN CASING THICKNESS A TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ni A <br />❑ VAPOR <br />O MUD ROTARY DEPTH OF GROUT SEAL 5 / TREMIE TYPE TO BE USED Q AUGERS ❑ HOSE <br />❑ AIR SPARGEIOZONE <br />❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes pp No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[SOIL BORING <br />❑ HAND AUGER GROUT SPECIFICATIONS <br />OTHER: ro <br />J <br />OTHER: APPROX. BORING DEPTH S ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES. list specific0ons in wmmenr section) <br />COMMENTS: <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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicable California Laws. <br />SignedPu <br />bcrJ+--�_ ^\�J� TitlelCompany�Val� G�`l t_Z�olP2@sVt�1't <br />� <br />Print Name t�OCrEt2 1J�C �C l BIZ Date_ J�ZZ6f d 6 <br />AJ. �DJE,�PA� <br />DEPARTMENT USE ONLY <br />N <br />SITE MAP IN UNIT IV FILE, ADDRESS: �� • ✓�iCUiY1 5fk-,-1Co -10-, <br />WORK PLAN DATED: b rS c., <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTSICONDITIONS: <br />DATEISSUED <br />FINAL INSPECTION BY <br />DATE—_ <br />L <br />AREA x'97 <br />DATE <br />ACCOUNTING ONLY: AID # <br />FAC # <br />PE CODES <br />FEE INFO AMT REMITTED <br />CHECK # <br />_ <br />RECV•D BY DATE PERMITISERVICE # <br />INVOICE <br />C-57 WC -WAIVER <br />EHC 29-01 11407 (WEB) <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />