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U►.�r San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 952 r II�. %'F ' tTIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.o / ? \ �J 1v/. `: jNIT IV <br /> ► o �'� Well Permit Application e i 1l L007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descnbed It>dn 1 compliance with San <br /> I'1 /i ,7 r't <br /> Joaquin County Developmentjitle,Chapter 9-1115.3 and theOStandards� of an Joa-Tv �q �County S` iy ronmert[ W��ddlkr0,t� palFAssessors <br /> I t^A K ilQ 1 - Cross Street CityS-roCk.1'0 Zip° ;2-1'1 Parcel# <br /> WELL Location ""' <br /> CD IA MW r-r� A'�;0C vat 644- 4�zz <br /> PROPERTY �SgU]Phone# <br /> owner 13{�o>z�,ibE G171 l% Address i3�'1 W,{Df5l9li�City S(®C TD Zip <br /> C-57 Contractor PC- -is*kO`kTtoN Address City Zip Lic#� hone# <br /> Consultant/sub Cntr S�RTt Fj),I�UIiTItJCi�ISA dressy TE��A�Ih �Q�t C ILic# !"d2`132 Phone# <br /> I(� `! t,-rvto %4. Zoo'-676o <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WO K TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ODESTRUCTION (choose type below) <br /> SOIL BORING# VER-BORE. DIAMETER <br /> RESSURE GROUT <br /> 0 WELL# GROUT SPECIFICATIONS <br /> a*Other <br /> COMMENTS: TI�MI'o�AR`f THAI W Ci Z2 01> W Ar(ER L��A SA 1P .tir �. <br /> I S I <br /> W09,K Pt Afr 1��4(,;L� - -v 7 �-�rpC N1✓p <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IA <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE b�f MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:�. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL iS Mk> , TREMIE TYPE TO BE USED: U AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Vges 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VrSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> cn►�ou iTF �LUR�'-Y o� '�`���� C-�MEtJj <br /> 0 OTHER: 69-AD 0 OTHER APPROX.BORING DEPTH LIS D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> G u-1CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �SA �5 (GMPf712+AR`�' C.ASII��i � ALKF 1Li. W iT1I C��i'07J1 ASCJI Tlt 1-)RA1Jo <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, les and Regulations, and all applicable California State Laws. <br /> v— Title/Company P��S1tE1.11 <br /> Signed x 7-�er <br /> Print Name <br /> �J� C :1 T Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR SS:• la3 3G f—(J61C /-(?� / " <br /> WORK PLAN DATED: � � 7 <br /> Date Issued � rea <br /> � <br /> Application Accepted By. �"�^'��n� V bl � A 6 � <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 7ACCOUNTING AID# FAC#FO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICEO QP(.s .� l L <br /> % b� SR# v 0IN'A36°t <br /> C-57_ WCC-WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc--�L <br /> EHD 29-02-001 <br /> 6/22/04 <br />