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FILE curl <br /> man Joaquin County ('o <br /> Environmental Health Department W L�� L� TE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 IVII ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd JUL 2 1 2005UNIT IV <br /> Well Permit Application ENVIRONMENHEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 /> Jo��aguin County Develonmanr Tlu< rna,aa,o_114I ....,d the Standards of.qan Inn—in County Environmental Health Department. <br /> iNiK�+F (�� / Assesso R � <br /> WELL Location �I��f/.S^'�r. /T Cross Street FAAmI 4 &eCity J r LICTM� Zip 9SZeW Parcel# <br /> PROPERTY <br /> Owner SAfJ _) :c�, in wr�Y Address 1$1,14 k1A204^ 4t.CitySTa IC zip SZ0Phone# 'L`->g '30$k <br /> C-57 Contractor Em Dn I W?Ail, Address al5ri 14ow& RP- City ALjAj Zip44ff13 Lic#(T4 VA 7Phone# <br /> Consultant/Sub Cntr !T.G r F• Address S9 7 SAAw k 4• City.STo iCrb Lic# • ZL) Phone# z,y- V b 7-loot <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING CPT �O�PRQBE,HjW10 NCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# r /"I4 �/'r'l Q OVER-BORE. DIAMETER <br /> 0 WELL# n PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS:�H fA%A� ►arc pIAN �AT'40 /t, n 21 r# <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> E MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: AIM <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NI/i TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL IZS f TREMIE TYPE TO BE USED: 0 AUGERS •HOSE <br /> n AIR SPARGE/OZONEWUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yesn No ),NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS ryAO/IT/AHO :50IK ,i <br /> n OTHER: fl OTHER APPROX.BORING DEPTH_f L'S ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED V14 (If YES,Ilst 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 /> 1 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 tate Laws. <br /> Signedx Title/Company AeJecT MaNA 9@.r / , C r <br /> Print Name f/M# AAK J . Cvl^)/q it Dale <br /> DEPARTMENT USE ONL�Y/ A /, n <br /> SITE MAP IN UNIT IV FILE, ADDRESS: s/ ( � L , G(/� <br /> WORK PLAN DATED: 5-I 'fl7r <br /> Application Accepted By Date Issued S D Area <br /> Grout Inspection By Date Final Inspection By e <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3(g 02 5$1 -7. 2 sR# 32_06 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> GR2/04 r <br /> 2 iq-os 9_oi-act's <br />