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I <br /> 0 IrA�Grpy <br /> o qan Joaquin County (�E <br /> i <br /> m <br /> IV-P Environmental Health Department ° u <br /> a ' 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 OC T VITI W ION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> Well Permit Application ENVIRONMENT HFAITH <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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. <br /> WELL Location T&h U,,ON Feff4 IV/CTdTl4Cross Street P("er IdW City t„�-�tC JO 95338 Parcel#%4!35/0// <br /> PROPERTY <br /> Owner K a lfaME' CEItT&L, Address 1?36P S101arCity L / O zip4 33D Phone# 916 -86q-/��3 <br /> C-57 Contractor V+W/QPt II1a0� Address /bb F/A k 641flrl City�/�� Zip j56'VLIc#7�Phone# Rl-6i77-N/0a <br /> Consultant/Sub Cntr /t 1e elder" Address lg;`S city- 76t/Lic# Phone# a�/-9 -/3v5� <br /> GIS Coordinates:X 'y ,Township Range Section <br /> WORK TO BE PERFORMED: `' <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') (DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 'OVER-BORE. DIAMETER /D r/ <br /> $WELL# M M- l 0 PRESSURE GROUT _1 /1 <br /> (]'Other GROUT SPECIFICATIONS T -T j9 AIA Ce Vexl <br /> COMMENTS: <br /> -rA"cc/l, 7J ew nrL Y°i/oe <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /y <br /> IA.OF BOREHOLE [Orr 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> -PONITORING 0 HOLLOW STEM Dy_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC ]]OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �-S TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: AYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS TrAe T/II Oxi Ce-ke-,t- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH ;,If a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED I (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 Ordinances, Rules and Reg <br /> llatt,00ns,and all applicable California State Laws. ,{ <br /> Signed / f� h/.�r�"'�-- Title/Company bo IC,`( deo ,5-7'- <br /> Print Name /�Ct/VUCDate /0130 06 <br /> DEPARTMENT USE ONLY <br /> p <br /> SITE MAP IN UNIT IV FILE, ADDRE S: O ODD t^' <br /> WORK PLAN DATED: 0 <br /> Application Accepted B Date Issued Area `mow <br /> Grout Inspection By Dale /1 ' 3-O 6 Final Inspection Byo //- .3 -Ore <br /> Destruction Inspection By ,P,T .e iirLUZ,If Date 11-3 -04, <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> U �Q°0 sip 1 �� SR# 1j3 <br /> C- WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/12/04 <br />