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unty <br /> San Joaquin Co � �1 L <br /> z cy Environmental Health Department �S1Tf <br /> < 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 DECIlAIATION <br /> I (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd 'UNIT-IV <br /> Well Permit Application ENPERMIT/Sw,iVICEST(I <br /> NON-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 /> (,� e, / / Assessors <br /> WELL Location Z3 Lv e� e Cross Street ,/Z'�,P/Z'7'cCity ./J+a=k l-a n zip' 5-zoe- Parcel# i <br /> PROPERTY Z�Icfs 5 WI v„/ ��t � �r Zi ��/O Phone# <br /> Owner S: - .I 9�to�k�US Addrhess y //i)p / 7 <br /> C-57 Contractor C%ry jDr, JE5+ T� dds�552916 W��1nnlr l/rJVt,7��- City/;; Zp�l07 c# (� � Ph e& 9ZJ'30-5 <br /> 'zc vivo H�IIsS `�. S A6 "rdwlice Phone# 610---Ieo-3308 <br /> Consultant/Sub Cntr G.4w•bn�'y h✓rV. ) Address ✓' 1 �ily <br /> GIS Coordinates:X ,Y ,Township. Range Section <br /> WORK TO BE PERFORMED: <br /> J IEW WELL/BORING (CPT,GEOPRVE,HYDROPUNCH,HAND AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> �\ OIL BORING# C JT- I"'> a a OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS i� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OFBOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br /> I 0 VAPOR �a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: -0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE �rUSH POINT(GP or CPT)GROUT.SEAL PUMPED: aYes O No (NOTE: MAXIMUM FRE E-FALL DE PTH IS 301) <br /> A\SOIL BORING O ANDAUGER GROUT,SPECIFICATIONS - <br /> Z 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX I or 0 STOVEPIPE <br /> 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinarl Rules ay4+19 uI tions d all applicable California State Laws. <br /> �. Signec!X -y+ _ q _ Title/Company <br /> Print Name_ I/) <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> �j/l.Cf /7(Ci20.�7rrea <br /> Application Accepted By '`-„1 \ � �) Date Issued <br /> i <br /> Grout Inspection By 6V Date U Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> TREQUEST <br /> ACCOUNTING ONLY: AID# FPECODES FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT I SERVIC # INVOICE <br /> DO H-T 3bµ SR# � <br /> C-57 WC=WAIVER_ C-57 Letter of AuthoCizw ion o sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br /> y <br />