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°t o *San Joaquin County C Y <br /> Environmental Hea#h Department ECE� ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 tel{ <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/chd OCT 1 0 AUTIGATION <br /> ENVIRONMENT HEALTH IT IV <br /> Well Permit Application _ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 with San <br /> Joaquin County Develo1'pme''ntt Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELLLocation �qoT W. ��1ar✓ (.t�ay Cross Street E�a,,�� No �J��� I� �Assesso�63 �_� <br /> T- ily�iW'+±Zip S Parcel# <br /> PROPERTY �j �L <br /> OwnerQC4` �e..61 Gt•ew,-eA AddPss %&0 '00ow $/jCity ZiP/s/��D3 Phone# <br /> C-57 Contractor 1 Address3Gf#{ Seri`5 ace c;ry 5 ,pw�S�9S2� <br /> Phone#ZOq- 2-350 <br /> Consultant/Sub Cntr Address i/y mM k S�• 5+.- City Nc Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range 9 Section <br /> WORK TO BE PERFORMED, <br /> ;ffNEW WELL/BORING ((CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> ;KSOILBORING# S <br /> D WELL# D OVER-BORE. DIAMETER <br /> a*Otherr L D PRESSURE GROUT <br /> COMMENTS: DireeiT -y(tjl,t GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D HOSE <br /> D AUGERS <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D YDes- ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING D HAND AUGER GROUT SPECIFICATIONS ue�lar. 4-e- <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 7r5' <br /> f'+ D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> COMMENTS: SOt <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> t � 6Q <br /> bk�`tl� w berms ? . <br /> NOTE: OFFSITE BORIN S REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have a ared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nc s, UI Re ations, and all applicable California State Laws. <br /> Signed _ 1 Title/Company er—1 /Lcedr <br /> Print Name 5� J• +-.�(,7 2 <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: l`�y` W. a„-rou t-Gf 2 lf, !0 0 <br /> WORK PLAN DATED: <br /> Application Accepted By '"g7atee <br /> Date Issued OArea ((OOQ <br /> Grout Inspection By Date Final Inspection B -25-0�- <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0 � a( ' /ZS /o�e SR# Q <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 />