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f <br /> San Joaquin County <br /> Environmental Health Department °� <br /> �, SITE.. <br /> 304 East Weber Avenue 3rd Floor Stockton CA 95202 " �y <br /> ' (209)45$-3449 Fax:(209)46$-3433 Web:Www.sjgov.org/ehd �!� ` ` 11ON <br /> f} '� UIYII� <br /> Well Permit Application F/,, <br /> MON-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 applicat(o)r'ii�ti*8;";041iance with San <br /> Joaquin County Development We,Chapter9-1115.3 and the Standards of San Joaquin County Environmental Health Department." . <br /> WELL Location 5 Lo(list Ave./i 5�s7'Y(4�M1y p�—Assessors �+fO <br /> Cross Street Ci llf0 21 d Parcel# "Z ! <br /> 'PROPERTY f.- (LG <br /> wmI / <br /> Oer W Sk 10k Address (0 (1ftkP,,i4 ��. City lis/ Zip�PhoneA ZS�_Z�j~3�lIJ <br /> C-57 Contractor W00a 911;I[IjA44. Address1 r_f City o V Zip �! Llc#71pU7 Phone# 707-�7 - Oa <br /> Consultant/Sub C IOA !AddresNb (ANUM P4 A- 'C_550 �gel"� -L Phone# 53Q-G (/-206 Z <br /> Gia Coordinates:X —Y Township Iry Range Section <br /> WORK TO BE PERF,QRMED: <br /> U NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') �KbESTRUCTION (choose tyl a below) <br /> ` <br /> 0 SOIL BORING# <br /> 0 WELL# VER-SORE. DIAMETER I8 r <br /> 0 PRESSURE GROUT <br /> O'Other _ GROUT SPECIFICATIONS <br /> COMM E NTS: <br /> TYf ELS INSTALLATION TYPE C N TR CTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE_/ Il MULTIPLE CASINGS 0 MULTI-LEVEL- WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TY E OF CASING: 0 STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA ' TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE a PUSH POINT(GP orCPT)GROUT SEAL PUMPED:)Ves� 4No (NOTE: MAXIMUM FREE-FALL':DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS��I f <br /> 0 OTHER: Il OTHER APPROX.BARING DEPTH 0 BOLTED TRAFFIC BOX or p 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 /> I <br /> I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin i <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Signed x JC[�(+6 Q TitwCompany11:16:1 Vigo ErAP <br /> Print Name ✓lA 91 4i+1 -v Date o`! <br /> DEPARTMENT USE ONLY- <br /> SITE MAP IN UNIT IV FILE, D ESS: <br /> WORK PLAN DATED: q I1 8 _ <br /> Application Accepted By r Date Issued 2*t o Area <br /> Grout Inspection By Date z O Final InsFectlon By pate1 z- I <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: i <br /> ACCOUNTING ONLY: AID# FAC# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3502 (PO-00 Z3�9Z (n,( =,-j SR# 5 Z3.ob t <br /> C-57 WCT-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 2M2-001 <br /> 6/22/04 i <br /> t <br />