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FILE COPY <br /> San Joaquin County (� <br /> z Environmental Health Department # ECE# ���ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdJUL Z 12005 UNIT IV <br /> Well Permit Application ENVIRONMENT <br /> HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMITISERVI ES <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 CountyEnvironmental Health Department. <br /> Civ.-Ary 4v8 V., F Assessors <br /> WELL Location 71QJ Ca,.,n1r„ Cid ross Street 6 FAA�uKIrn ,City 5TOC<TDW Zip 9$QQ Parcel# Z 2 <br /> PROPERTY <br /> !{ <br /> cdv,atr7 ve. <br /> Owner MA ,rte in Address 117,.3 �/y4 6/i�vA City-51!A K%onzip9S2o Phone# tvy .962-S22S' <br /> C-57 Contractor VPF� Of%Address rs0 /IAWr2 ID. D CRy T� LZip4yS53Lic#6S6y'O7Phone#ILS^Y/3^J� 0 <br /> 0 <br /> Consultant/Sub Cntr A ,G. Address 937 SHAW R . City5ToL<ton Lic# o Z2 Phone# ZOh- 4b 71/091 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW ELL/BORING CPT OPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# l s 3 0 OVER-BORE. DIAMETER <br /> p WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: 5£1 APPAZ\e 0 W o R K PIA QA7't0 l(e M9� 2 a o r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ���a <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE•• '',,,,��0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:M <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL 0 PVC BOTHER: MIA <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 126 r TREMIE TYPE TO BE USED: 0 AUGERS _)kHOSE <br /> 0 AIR SPARGE1 OZONEAPUSH POINT(GP or©P GROUT SEAL PUMPED: 'AYes =NOTE:(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pori IANn TypE 1X <br /> 0 OTHER: B OTHER APPROX.BORING DEPTH )ZS' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N A (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 /> 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 <br /> �Regulations, <br /> —and all applicable California to Laws. // <br /> Signed x —7.' 1 /-Ntl.f.Ql..� Title/Company �,FC 1 MA Ai4G(�'1P/ , �T <br /> Print Name I/MA7NIV J. CtidlAA Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: (2 <br /> Application Accepted By Date Issued (�z5 `� Area <br /> Grout Inspection By Date Final Inspection By Date <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 /> 355bb-0 36$ 2255 lel,� cl-zl SR#poq3205S <br /> C-57 / WC✓-WAIVER_ C-57 Letter of Authorization to sign permit Errcraachment doc_ <br /> EHD 29-02-001 d4e�—E21E: <br /> 622/04 <br />