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OPY <br /> r, r San Joaquin County FILE C <br /> 9 tY <br /> A o Environmental Health Departmen (� SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA.95ECE1J�� "IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ 0 2004 UNIT IV <br /> V 1 <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU V�R�NI �Ff�1���1/H(E�AcLTH MD. <br /> � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Th s 1pfi�atib�`f ade 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 ('� 111 L ,! Assessors <br /> WELL Location 1�t1 0 `�(�[UrKi0. �� Cross Street Ulal�tu� City S�tC��l1 Zip J��w Parcel# W-16-4-6o <br /> PROPER' <br /> Owner ltJ0.1454VQbal e�,c Address ((#1011. 0 0lpro,41-f City.-9Zip�77b� Phone#(ZD�t) (oZ38; <br /> C-57 Contractor CAStATC-'Dr I I I C►3 Address 5W bmft CWC le City L�vf4vVA Zip 45'1#t Lie#7/ Phone# <br /> Consultant/Sub Cntr ,AAddress 637 Ska, IM� city it Lic# 4122 Phone# (20R)q7—/00(, <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> a SOIL BORING# 49VER-BORE. DIAMETER_ <br /> a WELL# bl W—4 PRESSURE GROUT <br /> a*Other IT <br /> OUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL . INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,;* ONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL (]PVC a OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING D HAND AUGER GROUT SPECIFICATIONS_ <br /> OTHER: OTHER APPROX.BORING DEPTH t . I --•z,BOLTED TRAFFIC BOX or 0 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 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. <br /> Signed x a Title/Company I Jnat C�GCxV j jvu <br /> 9 <br /> Print Name �—' `'� Date 0✓+ ��T o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued ' Area <br /> Grout Inspection By Date Final nspection B —VjMSate 1�� <br /> Destruction Inspection By Date "( ' <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ;,?qo �l IIINO <br /> a <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dock_ <br /> EHD 29-02-001 /467 �C <br /> 6/22/04 #t <br />