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ECEIVED <br /> San Joaquin Count <br /> Environmental Health Department AUG 1 2 2005 SITE <br /> ' <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95 i <br /> ��•'•. ' ' •. �S�tv,loAt�ulNco�nrrirMiTIGATION , <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/EWiON i <br /> ' HEALTH DEPARTMENT UNIT IV <br /> a <br /> ,0 Well Permit Application <br /> r 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 with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the StandardsI of San Joaquin County Environmental Health Department. <br /> WELL Location <br /> 1$0 5 40r60r S�' 4DL AA5GIG3 Assessors rv! `y <br /> cross Street City. ST K. Zip 95103 Parcel# I ` 10 0 <br /> PROPS TY 4743Y ,�4 <br /> Owner r1 O v Address 7 w k A,,e Fla r City ¢ow K Zip 1p17 z phone#+Z��`ad1-5301 <br /> C=57 Contractor s Ca C, Address-1163L QME(, City -c—'16 O Zip g57�&C#71'7NO phone#. <br /> Consultant/Sub Cntrl Ca F_ —Address '23? �1 u.,ftj City S-T Ic Lic# (P OOdL27 Phone# 11(p-1 1 OOL <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ;DESTRUCTION (choose type below) <br /> 0 SOIL BORING# -OVER-BORE. DIAMETER $ <br /> 0 WELL# 0 PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS. ' <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I(MONITORING XHOLLOW STEM DIA.OF BOREHOLE �' MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL %PVC 0 OTHER: { <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 0 7 TREMIE TYPE TO BE USED: 0 AUGERS la HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FAL( DEPTH IS 30) µ <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS &ft A. L 16 <br /> 0 OTHER:_U OTHER APPROX.BORING DEPTH 30' 0 BOLTED TRAFFIC BOX ors p 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 tha I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi n s, Rules nd R ulations,and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r�2 0S� <br /> WORK PLAN DATED: <br /> Application Accepted By h W r Date Issued A V Area <br /> Grout Inspection By . Date final inspection By ate 1,Aa <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 I SERVICE REQUEST# INVOICE <br /> i <br /> C-57_ WC -WATVER C-57 Letter of AuthoriKcti /to sign permit_Encroachment docs <br /> EHD 29-02-001 ` q <br /> 6122/04 I, <br />