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_San Joaquin County ;. <br /> ` Envie _ mental Health Department mDE 'C�' <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITION <br /> (209)468-3449 Fax: (249)468-3433 Web: www.sjgov•org/ehd AUG 3 D <br /> WT IV <br /> Well Permit Application ENVIROM"T Wr-A'IH . <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED pEMMMSERVICES <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 /> + r Assessors <br /> WELL Location 16,417-S- JA) ,Cli!-_Ir�, C1 _ R� Cross Street v City ajjpsc,e zip oCR Parcel# 1$q-250 2_1�, <br /> PROPE=RTY / <br /> Ownerdei-i �fa ,tit �-Address_Lg30 U}�,;j�� pr Cid, Zip `TS3Yp Phone# <br /> C-57 Contractor Address q d awe City-Zip 1/53 Lic#CoSioK}"!Phone# 4Z5) <br /> }} —3l z—Sgoo <br /> Consultant/SubCntr_A&rF Address_�37J1 SG�,r �. �City fa,, Lie#_6_RDZZ? Phone# <br /> li ' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 84'VFW WELL/BORING CP ,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 19'5OIL BORING#_ GPT--��{ ('f 6 <br /> 0 WELL# � ,�\ 0 OVER-BORE. DIAMETER <br /> l <br /> 0`Other Q PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE -4" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRfVEN CASING THICKNESS , <br /> 0 VAPOR -- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: KIA <br /> 0 MUD ROTARY DEPTH OF GROUT SEALS-� TREMIE TYPE TO BE USED: U<UGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 015U-SH POINT(GP ortaGROUT SEAL PUMPED: <br /> E'SrOIL BORING 0 HAND AUGER 0 Yes B'f�\ (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS or q^J <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> I� 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 /> 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 Regulations, and all applicable California State Laws. n ` <br /> Signed x � Title/Company eo�o `rt Ac-F_ <br /> i <br /> Print Na e -_ ,�,�.� p -OS <br /> Date 8-3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /CSGc' IRIV <br /> WORK PLAN DATED-: ,/fl v�.s, /d j" <br /> Application Accepted By /1/1 ��✓Pu:�Vss14 Date Issued <br /> Grout Inspection By Area <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> ��c-i C'N 7-le /3L c� S R# 0 0 i(3 7 340 <br /> 35� 3 z�9 �' 3E& 3149 <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 /> . fw <br />