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San Joaquin County h r <br /> E COPY <br /> Environmental Health Department W� SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 (�DEC 1 1fibATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/chd <br /> `' AIV <br /> Well Permit Application ENV) NN <br /> ROicN� KNIt <br /> PERMITi <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED off <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance 11th San <br /> Joaquin County Development Title,Chapter 9I-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location R( Zcx'> Lc r�lx)(A(fL S'I-. Assessors <br /> Cross Street T;cC ne Ciry Lr< ZipSS]A Parcel# <br /> PROPERTY f� .. <br /> Owner C%,'!�� acale Address 167Ao Cr- r'�r� sr��. City L=Ltrz�i zip 5!r 30 Phone# <br /> C-57 Contactor(nk+cc =<'-s Gk lr;11.�Cca Address 550 t2-;��C t41. City '�L)�` • Zip4`I�7Lic# �IiPhone#('b4)3�`/-Y3CU <br /> Corso ltanllSub Cntr lC)h- :Zrit. LnC, Address.2tIT I�;J�oZ ZI,�$ ,la)City MZc, Lic# Phone#1,%)s c'i-0'Yocv <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: - - <br /> 9NEW WELLY BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) n DESTRUCTION (choose type below) <br /> a SOIL BORING#_ r'� a OVER-BORE. DIAMETER <br /> •XWELL If i a PRESSURE GROUT <br /> a*Other��� GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING $HOLLOW STEM DIA.OF BOREHOLE I" E MULTIPLE CASINGS g MULTI.-LEVEL WELL CASING DIA:-;-L'-- <br /> 1]EXTRACTION- (]AIR HAMMER/DRIVEN CASING THICKNESS 'L, 0 TYPE OF CASING II STEEL gPVC []OTHER: <br /> 11 VAPOR D MUD ROTARY - DEPTH OF GROUT SEAL 2. TREMIE TYPE TO BE USED: O AUGERS WHOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes <br /> Jr (NOT_E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0SOIL BORING U HAND AUGER GROUT SPECIFICATIONS <br /> a,OTHER: n OTHER -. APPROX.BORING DEPTH - 2 S IrBOLTED TRAFFIC BOX at 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 1 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 ?< ✓6� - rue/Company S4 ( � 5_;e_4;-_1 /t; r c 0%L <br /> Print Name ` KI t t) :n Date. /Z <br /> DEPARTMENT USE ONLY p <br /> SITE MAP IN UNIT IV FILE,ADDRESS: - /0/ <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued MWED <br /> Area <br /> Grout Inspection By Date Final Inspection By to <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> D MW t <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 ( . <br />