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• o�"""�• c 4kan Joaquintounty <br /> • FILE COPY <br /> Environmental Health Department <br /> SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton CA 95202; +: <br /> L,G�1�'-I_rd i/,rlVfkT1C3i4TION <br /> r ' (209)468-3449 Fax: (209)468-3433 Web:www.sj'gov.org/ehd S p?l!!G�NIT IV <br /> Well Permit Application <br /> 04 SEP 10 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad co <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. an <br /> WELL Location B-04 Wt �.u- day Cross Street frti-kn I�JL City��,.l-gH Zlp Assessors <br /> —� 95206 Parcel# <br /> PROPERTY <br /> Ownerj%6A"( CLCR I / roAddress?(p (?&,'�6OW DIVA. City N GC�alrA �115 zip 903 Phone# <br /> C-57 Contractor ly tl fk rl(h"KCm �1 Address ?qq 5II n'5 ffaet City Sor�,Y Zip jS2 Lic#�,Q / phone# 2tJQ-}}Z-35?p <br /> Consultant/Sub Cntr6:014a.+Y,y mast I6ij5ddress 2Y4y t•M,l City��6(tn _Lic# <br /> Phone#_—53 -2-6 <br /> GIS Coordinates:X ,Y ,Township Range 9 Section <br /> WORK TO BE PERFORMED: <br /> ,H NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> aWELLB# RING# D OVER-BORE. DIAMETER <br /> 0•Other .I 0 PRESSURE GROUT <br /> COMMENTS: <br /> GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEf,_75-' 0 MULTIPLE CASINGS 0 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 0 MUD ROTARY DEPTH OF GROUT SEAL S,5 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MA&MU F E-FALL f PIV IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIO L AJO I <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH S.S ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:�b r) IA�Yr 6-,- , µ �$' w11 <br /> Ix- a �( W <br /> NOTE: OFFSITE BORINGS REQUIRE ACC SS 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 Ordinan Rule an Re ulations,and all applicable California State Laws. <br /> Signed / <br /> --�' `` <br /> Title/Company J"uIAfy 1 p <br /> Print Name_ I r ln,� �p.1,1 {�/ Date <br /> D,EE�P,ARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <E W/ G " ' CI�iC!!�Q CG3 <br /> WORK PLAN DATED: ——2,00 1 V Application Accepted By Date Issued Area 66? <br /> Grout Inspection By51ZDate Final Inspection B ate <br /> Destruction Inspection By Date O <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0 SR <br /> 10 7Z <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc-014 <br /> EHD 29-02-001 <br /> 6/22/04 <br />