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San Joaquin County <br /> Environmental Health Department (� ITE <br /> X-A304 East Weber Avenue 3rd Floor, Stockton,CA 95202 �u��GGATION <br /> w e' <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd NOVQ 5 2004 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SE/ENT HEALTH <br /> ERMITitSE <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 JoaquinCountyEnvironmental Health Department. <br /> r r�C'i� 6 • 1 City i p �53�b Assessors <br /> WELL Location Cross Street �x--t(�T� Zi Parcel# <br /> PROPERTY '//" p <br /> Owner tt�,,��,�'' U ��tt Address Qan}• Ic.Ipli,wt,"l�C City � `ham L Zipq�O&Phone# Uf— `T Kl 0-JMO <br /> C-57 Contractor_�yy4VJA1 rilithO e0: Address PO Pox 33� Cit fb VIV-4 Zipgg57/Lic# V/0677Phone# 70 3-•3-7q-Ll300 <br /> Consultant/Sub Cntrc Ch V'{ kC.h/..TYIG• Address i 1211q&1.14,4 City Lic# 1DIC 18( Phone# //�-�5� d21/ <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER Ulf <br /> $WELL# Q PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> HOLLOW STEM DIA.OF BOREHOLE <br /> a MONITORING Y Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS-fyk4(7 pVL TYPE OF CASING: Q STEEL Q PVC BOTHER: 1 <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 2V-Feat TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes_4No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 1 v PZ 001yNen4 <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH -• Q BOLTED TRAFFIC BOX or Q STOVE PIPE �t <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) l <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed xTitle/Company ( L G7 i"TC ..7L/y C <br /> rEt4 <br /> `` V -77w- <br /> Print Name ( �`-'l,ttv- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 15 9/ 7C <br /> WORK PLAN DATED:yin 2dD <br /> Application Accepted By �C/ eta/ems U%� Date Issued �z�Z 6L� Area S3 <br /> Grout Inspection By Date &19-.14010VFinal Inspection By r/ Date �2 <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 /> 00W SR# o 01(0 5,f7 <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 />