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San Joaquin County <br /> 2 i Environmental Health Department Fp) =� E_� ,..SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 �� � 7fATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> ,, <br /> UNIT IV <br /> NOV 0 5 2004 <br /> q�rFORa Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NVIR�NPERMIT�ioE,,ISE �"T HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic tion i compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 J c F Assessors <br /> WELL Location � l`(ff_;� Cross Street '✓��s4yee_y City C�•:�� Zip '533( Parcel# <br /> PROPERTY C om. , - f-w0– r/_ p <br /> Owner Address Qvv_n}�f +`�.1nk"6_\tik\ City &�V�` 7_ Zip47633bPhone# �'7— `T Y1 d -JMO <br /> C-57 Contractor A tl wka t 1 �ddress Zip 1 <br /> n _ PO Pox "33nn 1v city t)V s� �l"q5- l Lic# 1/06?Phone# 701-37�F y3oc <br /> Consultant/Sub Cntr AP:gk k-Tnr- Address //Zlfq 14 N city �Y Lic# 70(C ( Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f <br /> 0 MONITORING `HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:_Z <br /> 0 EXTRACTION /a AIR HAMMER/DRIVEN CASING THICKNESS'�*th40 PVL TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z0.1-ez4 TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes J(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS -1 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 2_ - fee,t' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 1 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. n <br /> Signed x� �" [�LTitle/Company �ALX EN U I ea) <br /> Print <br /> �� <br /> Print Name ( GLV t y l Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S`f 7,- <br /> WORK PLAN DATED: !`( t7Gunarcat 7 7 <br /> Application Accepted By '4�C/ r PrlO��`w'� Date Issued zle2 Area <br /> Grout Inspection Ey 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 /> '35,01 M G-) 14S) " X 65-6 sR# o o>{0 5,t7 <br /> C-57✓ WC_ -WAIVER C-57 Letter of Authorization to sign permit -!Encroachment doc ✓ <br /> EHD 29-02-001 <br /> 6/22/04 <br />