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SAN JOAQUIN COUNTY ITE. <br /> �? x IRONMENTAL AiALTH DEPART CMGATION <br /> CeygLrst Weber Avenue 3rdFloor Stockton CA 9520f- <br /> NI <br /> (209)468-3449, Far :(209)"468-3433• Web:www.co.san-joaquin.ca.us/ehd <br /> U T IV <br /> -JUAV 17 2004 <br /> ENVIRONMENT HEALTH WELL PERMIT APPLICATION FORM CO. 0 C U) <br /> PERM IT/SERVICERON-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. <br /> .. - Assessors 1 <br /> WELL Location 1910 CCtrl QUI? RLVd_ Cross Street i"11 S1Oi7 City 2DWM Zip 952M - Parcel#_ulkhar„n <br /> PROPERTY Owner - Address 111�1 .E- ibZeltCri City aQg� Zip95205_Phone#-20 <br /> C-57 Contractor WDOdMard Df 111r9 Address" P-C- lox 336 City FSO Vistazip 94571 Lic# 71fl079 Phone# i <br /> Consultant/Sub Cntr Addres 1386 E BMM2r a City Waojl M Lic# 51 `7 Phone#530 :Tn <br /> Gly Coordinates:X Y'." '" Township 1N "Range - 5 Section 4 <br /> WORK TO 13E PERFORMED: <br /> EW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER"). .0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# OVER-BORE-DIAMETER <br /> WELL# MA i 411- 0 PRESSURE GROUT <br /> O'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> 5MONITORING EPIOLLOW STEM DIA.OF BOREHOLE 8" MULTIPLE CASINGS?0 YES ANO WELL CASING DIA: 2" <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Sh�40- 'TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 10.5' TREMIE TYPE TO BE USED: 0 AUGERS NOSE <br /> l]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') j <br /> 0 SOIL BORING .Q HAND AUGER GROUT SPECIFICATIONS: NPmL Com_1t W1t;Y1 5%. bO7tal1t <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 1 H; ff BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?�nn (if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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, ' le a d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company �jLrat GeolcgL5t In <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLI <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �� / / <br /> Date Issued <br /> 6�l �O Area <br /> Application Accepted By AWA <br /> Grout Inspection By <br /> Date Final Inspection By� . ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT!SERVICE"REQUEST# INVOICE ' <br /> ��1 Mw S7 S ro-1 o SR# 'DD 3� <br /> Encroachment oachmen <br /> t doc <br /> 'o`si n ermit _ <br /> C-57 WC -WAIVE=R C-57 Letter of Authorization t g p -- <br /> wELL PERMrr SITE <br /> EHD 29-02-001 - - <br /> 8/2712003 11 <br />