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i <br /> / Q Wan Joaquin County 41 RIECSWIEg- <br /> Environmental <br /> Health Department <br /> < 600 E. Main Street, Stockton, CA 95202-3029 OCT IlllITqGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> CpC%�oR�`P Well Permit Application EN1 fNUL �DH <br /> PERMITISERVICES <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 made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 14,4tl gips" <br /> 6 Assessors <br /> WELL Location �,.Q ro�t,tf Lk Cross Street t- � +"tem , City (-ul, Zip t�� � Parcel# J4) 140 3PROP <br /> Owner TY i} o. I_"r{ hZ� ti1/� lal1�, �S��o <br /> Owner � j( `� t� Address '� �'• City (� Zip Phone# <br /> C-57 Contractor �dy l �v1 t.p )iu Address (-m ' City '°�t�j�r Zip 145.?.1 Lic01007 phone# '70-1'74'L0J) <br /> Consultant/Sub Cntr �4 QkvRron Vnyat,j Address City PIit Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOP ROBE, HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> []SOIL BORING# 0 OVER-BORE. DIAMETER <br /> []WELL# RESSURE GROUT <br /> [J*Other GROUT <br /> SPECIFICATIONS �� ctt� <br /> COMMENTS:_M�,1��� MI„I''�I /t't I1,V -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS e <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION t�AIR HAMMER/DRIVEN CASING THICKNESS $Ci TYPE OF CASING: []STEEL PVC 0 OTHER: <br /> []VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or []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 <br /> /ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x ! i / <br /> �/" P <br /> /' � r� ) <br /> Print Name r �t � tl tL'.�l �'�� Date j t01/� `�/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ESS: 2-Z-C S- I L0 4- lop-s2t <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued /0-7 rea <br /> Grout Inspection By Date L 6Z D Final Inspection By Date <br /> Destruction Inspection By Date �Q � D <br /> COMMENTS/CONDITIONS: r' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> b boa o.4b !38 <br /> L01 SR#00S-7g6ti�e <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />