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f-� � NT FILE COPY <br /> oe Vly ' b San Joaquin County <br /> Environmental Health Department MAy Q4 t� SIS TE -1 <br /> 1 P <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 GeIGATION' I <br /> i (209)468-3449 Fax. (209)468-3433 Web: ww.sJov.or /e•� JOAODDUNbNTM <br /> NITI <br /> tr"� a NREPp � <br /> Well Permit Application HST" <br /> I 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 complianchth San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department it <br /> - --7^� . . . a a' Assessors. A� pOw !! <br /> WELL Locatio'e2252 f�i4�.,,J.n4- _Cross Street."6 qy- _ �" City ✓rtfGlL dYL Zip RSZOE_Parcel# 666 <br /> I PROP ,TY .. <br /> kS Owner AddressZ.ZEtJ.st' �eJo4^ �Ut.3�' CiryILYO//t'1����'�Zi��p- r�w�Phone# 1-$411 <br /> "I C•S7 Contractor rr - yla(Address 3��2 oW1e11G11}Cit2^e1e� Ci�GUr�tOwe' Y4p C(57147�1�17510Pnone# ' _ <br /> Conaulfant/SuhAq�9Yt CMVLYNibtVNUA'�al TU6tltlress D W w�iJ�CityU.I/OfAclp$t��c% T&* t17 Phone# )G 3q-�t70 <br /> GIS Coordinates:X ,Y - ,Township 'I N S Range <br /> R.(o� sectien zil . <br /> WORK TO BE PERFORMED: ht <br /> /NEW WELL/BORING (CPT,GEOPROBE,HVDROPUNCH,.HAND-AUGER OTHER') p DESTRUCTION (choose type below) <br /> p SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# M t - - _ n PRESSURE GROUT <br /> p*Other - GROUT SPECIFICATIONS - <br /> COMMENTS:�,JoviL SL beu.en/cQou:e, ui e.SlOP hlnirJ5Ts.7xr,i4 6T irlc+Trisa4 fev%,,d Ch�Itf53S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS e 'w .+ <br /> j MONITORING J HOLLOW STEM DIA OF BOREHOLE E MULTIPLE CASINGS (J MULTI-LEVEL WELL CASING DIA:�iw L <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS crkaJ NTYPE OF CASING: n STEEL I f PVC 0 OTHER: r <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED /AUGERS ` Q HOSE <br /> p AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED; p Yes -j No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') . <br /> n SOIL BORING 11 HAND AUGER GROAT SPECIFICATIONS VlecLi Cj__w-@Y i <br /> n OTHER: R OTHER APPROX.BORING DEPTH 60 BOLTED TRAFFIC BOX or p STOVEPIPE, I <br /> i CONDUCTORCASING PROPOSED" tjo (if YES,list specifica5ons in comment section) - <br /> COMMENTS: - - <br /> { NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROAC"MENT PERMITS. <br /> j 48 WORKING HOURS NOTICEREQUIRED'FOR INSPECTIONS. r <br /> I hereby certify that I4ve prepared this application and that the work will be done in accordance with San'Joaquin <br /> County Ordina y, R s and Regulations and all applicable Californi State a s. <br /> /j� 2t! 'Yt*ox <br /> Signed / ,. _ Title/Company ' <br /> —0- <br /> y <br /> ? Print Name �SC. ?� may` 9• 7 7�% Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z ZSS E- 'f ��/� <br /> WORK PLAN DATED: EC Zsl� K <br /> Application Accepted B 4 Dale Issued Are_a <br /> y <br /> Grout Inspection By Date b Final Inspection B e-__ <br /> Destruction Inspection By Date .. <br /> COMMENTS/CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# ' FAC#.. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE. PERMIT I SERVICE REQUEST# INVOICE. <br /> o ' 6 S- sR# 1010 33 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment/droc_ <br /> EHD 29-02-001 '0. �G, <br /> 6111/04 <br /> K <br /> t <br />