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oPq N.. -an Joaquin County <br /> Environmental Health Department o �iSITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9520.�� L1VW'GATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjcov.org/ehd UNIT IV <br /> �.;• �P' ,li it � 5 2006 <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE6NVIROI:IIEMT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. TRMI!T9ts n sv'Cd Sn compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> dI Assessors <br /> WELL Location 013 <br /> -,1Q..v. r. Cross Street 0, fie_ City Zip')SZofo Parcel# 1`1So3: vo <br /> PROPER <br /> Owner '+ n C(vvOG4oi Address Z21 t K1,�rLl ��oh .City S -03Phone# �`1.�1�t� ,0-kb <br /> C-57 Contractor Ur 11.E Address `iSO E4o ae 1124 City1`(ann✓ Zip�l�t5 Lic#LI'6l(,�Phone# <br /> Consultant/Sub Cntr �� �etz HS «., SA <br /> Sddress 9b iS S� (alt,,,,,, City Y mak-,I Lic#t14'&S T+N-9-- hone# 5b3.`12'-% 4-Toct x <br /> GIS Coordinates:X G 32i}b ,Y Z 11.06 to 3 Township i r ) Range E Section l}1✓t <br /> WORK TO BE PERFORMED: <br /> ,,NEW WELL/BORING (CPT, GEOPROBE,HYDROPU NCH, HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 1PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE APUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS d <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, R(( I <br /> Rules and Regulations, and all applicable California State Laws. �\ <br /> Signed x �,_A.,ZLL—, , Title/Company <br /> Print Name Date 12�1a6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ,APPRESS: 6'I'� - l Sawiczy °I <br /> WORK PLAN DATED: ..__ OO 2-`� <br /> Application Accepted By /1/� �� Date Issued Area <br /> Grout Inspection By Date ( Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS:C "\.)0 c l-3 .ik S r ,5TTti a .?� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,L9,01 `t` lea v6 sR# C,)o y 7S <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 />