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,o. o San J my <br /> Joaquin Cou fr ? i ;ii <br /> G Environmental Health Department' � SITE <br /> y ; <br /> C �� �, <br /> 304 East Weber Avenue, 3rd Floor, Stockton, A 95202 2 4 d. <br /> �.: WIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org"/eh �VVIR�jUr UNIT-IV <br /> a '�/1t�P� <br /> `' .g �,. Wel! Permit Application PER0TIS jrHE�� <br /> s 'LAS <br /> NON-REFUNDABLE PERMIT EXPIRES 1-YEAR FROM DATE ISSUED' i <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 Stand ards of San Joaquin County Environmental health Department. <br /> Q f 1 Assessors <br /> WELL Location t= t wC1 gia Cross Street $ <br /> e_i/ � � <br /> cityOc.� fya Zip `Z3) Parcel# —2 } <br /> PROPERT l <br /> Owner I (]�� i� Address`�337 i��Cernme�l lIc�CCity C YJ <br /> Q_gffi Lt{c <br /> Zip� Phone#Q00� W5''2-`i 00 <br /> C-57 Contractor_ 6fg Address 950 Het-UC CeA :! Cit NP{ ')—U._,zi PjX31 <br /> is# Ph.ne#( Z ) 31�j $ JG <br /> c <br /> Consultant/Sub Cntr '51-(-DR Address 50111 ,I Q;r t� 5aktk G-ity Llc# 6t�y�Phone# %6) 861`ND6 <br /> GIS Coordinates:X 'Y ` ,Township_: N Range L3 i= Section 30 <br /> WORK TO BE PERFORMED: <br /> I <br /> NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> XSOIL BORING# SES,tZ� S i 3 SP,'- 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING AlHOLLOW STEM DIA,OF BOREHOLE 13 0 MULTIPLE CASINGS _ <br /> 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: fi <br /> 0 VAPOR OM.UD ROTARY DEPTH OF GROUT SEAL ly� TREMIE TYPE TO BE USED: AAUGERS . .0 HOSE Q <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:; XYes q No (NOTE: MAXIMUM FREE-FALL DEPTH IS.30')' :. <br /> ASOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS (,W -LC Men _ <br /> O OTHER; 0 OTHER APPROX.BORING DEPTH_140— 7�2 BOLTED TRAFFIC BOX or 0 STOVE=PIPE,' <br /> CONDUCTOR CASING PROPOSED (if YES,list specificationsincomment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS.; <br /> �o <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. oG <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x TitlelCompany 5� SF_W _TjA illll4{14 ��+ <br /> Print Name t� (�r�sh� _..._. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> p lb-2/6 2 �` <br /> Application Accepted By. / +'�/� bate Issued -1 f r CfQ y Areae <br /> Grout Inspection By Date /1 b Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: G C oP S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE .. <br /> 3s orC, 4 ;L- o SR#1 Dt�3 <br /> C-57— WC=WAIVE=R_ C-57 letter of Authorization to Sign permit Encroachment doc_ <br /> EHD 29-02-001 - <br /> 6122104 y <br /> tt ' <br /> 1 <br /> rte: <br />