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A <br /> ICI 11 vy <br /> ` 'San Joaquin County ,�, ALE COPY <br /> Environmental Health Department J J 5 2003 <br /> 600 E. Main Street, Stockton, CA 95202-3029 9'�V1R0tJI`Ji[idl HEALT!'$ITE <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd -­­" <br /> A t T/J`n�110ACf IGATION <br /> <`FoaN Well Permit Application UNIT IV <br /> HON REFUNDABLE PERMIT EXPIRES", 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�I S) �o .nq n cq,n"• CIv6 01.E Assessors <br /> r I CLL& QwU Cross Street F City $10(I(T9n Zip Y62o�j Parcel# <br /> PROPERTY <br /> V E <br /> Owner oNn/ n,glCt� gddress ZIS/ Gvg <br /> C� ^— riven City Llg& fc.Zip 52oyPhone Zoq t/(o -Z7/S^ <br /> C-57 Contractor A.6.� . Address $37 SHAv✓ rQd Ci S1olKTe 9- -11 <br /> �/^� tY ,ZIP Lic#U0f17Phon Z%'Y Y674006 <br /> Consultant/Sub Cntr_A . Address j ,Fd4v✓ Rd City SrocKr>., <br /> Lic# f 1912 7 phone#Lsy <br /> GIS Coordinates:X Y ,Township Ran e <br /> 9 Section <br /> WORK TO BE PERFORMED: <br /> �QNEW WELL/BORING (CPT,GEOPROBE YDROPUNCH,HAND-AUGER,OTHER•) p DESTRUCTION (choose type below) <br /> /'801LBORING# - 7 •Zo <br /> 0 WELL# DOVER-BORE. DIAMETER <br /> 0.Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS:_ SE F ND — 090Rove O WORK <br /> s <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: '�/A_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL 0 PVC <br /> 0 VAPOR O OTHER: N A <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL S f TREMIE TYPE TO 8E USED: GAUGERS CHOSE <br /> p AIR SPARGE/OZONE APUSH POINT G®or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIM,UNM— FREE-FALL DEPTH It 30) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS tppr TIAw� Tyne- IL <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH S' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> r� CONDUCTO CASING PROPOSED Lv (if YES,list specifications in comment section) <br /> EE <br /> COMMENTS: 5IkHO --/aDpR,nln.l e k,r ctAT£V1_CQ/121c17 <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 Ordi nces, Rules and Regulations, and all applicable California State Laws.. <br /> Signed xe7 Title/Company R 'tlS �o I E <br /> Print Name �/� Date O/ 25 <br /> DEPARTMENT USE ONLY \ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �cS / ' N6 IV U <br /> WORK PLAN DATED: d J /7 An <br /> Application Accepted By Date Issued / f% V Area D� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE13 FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE IT I SERVICE REQUEST# INVOICE <br /> ?5%0 194303,co 1 b -25 0jSt 0j 3$G <br /> C- WC -WAIVER_ C-57 Letter of Authorization to Sign permit Encroachment doc I✓ <br /> EHD 29-02-001web <br /> 622/04 <br />