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,otgD' oo San Joaquin County <br /> Envil0mental Health Department Ok SITE <br /> a• a <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 nE %IGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd h! '�P <br /> Iro"`' Well Permit Application <br /> OEV— <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUS 3 ®'2005 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app il�Gcr�� iS�iEn iy0ce with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Db €L <br /> WELL Location 4 0 iM NQI I)IV� Cross Street hf✓t✓1q Y1 1($ty hTG G Zip 95TParcelll##br.��, 1��4�'39, <br /> PROP ; p <br /> -71 <br /> Owner OWC)jYUQ y- ` _ p� A1 _ one p <br /> C-57 Contractor yam60 " Address Ci <br /> Zip19 I1 Lic#46OWPhone# r4O 17 7 <br /> 110' 06 <br /> Consultant/Sub Cntr JA94(441)&A2 _Address 037CitiAat- 7,A Lic# U0Z Z Phone# - 06 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:WA-- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�A-TYPE OF CASING: D STEEL 0 PVC D OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL FiVt4-;n(. TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> 0 AIR SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes R-W (NOTE: MAXI UM FREE-FALL DEPTH IS 301) <br /> *OIL BORING D HAND AUGER GROUT SPECIFICATIONS "d hf I i I,/ <br /> D OTHER:_n OTHER APPROX.BORING DEPTH 25-V•eA* 0 BOLT TRAFFIC BOX or 0 STOVE PIPE <br /> L <br /> CONDUCTOR CASING PROPOSED w�(� (if YES, list specifications in comment section) <br /> COMMENTS:4�diT�{T9 /JOY `f�S Ar SOL <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 in accordance with San Joaquin <br /> COU <br /> n Ordinances, Rules and Regulations, 1d all applicable California State Laws. <br /> Signed x� Title/Company <br /> Print Na I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 930 WIcAArrt� <br /> WORK PLAN DATED: `d 13t2I o <br /> Application Accepted By Date IssuedtZ`,/05 Area Z! <br /> cl <br /> Grout Inspection By U� �AAAAZ- Date � b Final Inspection By U MA... r,, DateT>'65 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK If REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Zao( ,oG <br /> -z e, C16�' <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ C��� <br /> EHD 29-02-001 <br /> 6/22/04 <br />