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P *San Joaquin County <br /> _A cz Environmental Health Department �TE <br /> " K 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwwmsjgov.org/chd NOV 6 2000UNIT IV <br /> <rFoR Well Permit Application ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERACES <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 Standards of San Joaquin County Environmental Health Department. <br /> SOU S. <br /> I' 0 Assessors <br /> WELL Location / 4& I IA hJ Cross Street V,Lia-Xnan QA City Ffe A Zip 9-5,23 I Parcel# <br /> PROPE TY <br /> Owner itis/. Cane Gre.;,) f lav" lAddress P6 Box 9l city-ED ACc�y^ Zip 95,231 Phone# <br /> C-57 Contractor RSI>�;I�� y^c. Address.V6 N. C4-s+ S4 (n� City K006'IAJ Zip t5MLic# 8334 Phone#53046$.24;��I <br /> Consultant/Sub Cntr A G rL. Address S37 St,cw V JI CitySy'1C Lic# Phone#20g N�7/AO(o <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> $SOIL BORING# ST- I a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA,OF BOREHOLE 5.15 a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> g EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEALTok4 Oo•Ptk TREMIE TYPE TO BE USED: GAUGERS HOSE <br /> n AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: V'Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> � ^ <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS SC(IC Y0AV-D <br /> u OTHER:_0 OTHER APPROX.BORING DEPTH (76 , a BOLTED TRAFFIC BOX or a 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 certifyohat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O nces RuLes and Regulations, and all applicable California State Laws. <br /> Signedrz Title/Compane� <br /> Print Na e A,c&,4 �or A G f Date Co-O(o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: cl s0'-1 14w1 to H YLCC�( <br /> WORK PLAN DATED: tv (z& job <br /> Application Accepted By C� Date Issued I t C, Area <br /> Grout Inspection By liA,�r� Date R12-010Final Inspection By (�(,�a..nne�..-- Dateit w D <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z9o1 gj'61.00 7-` -436 Ott )lfi3/o6 SR# � �;-+o <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 />