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x <br /> Joaquin County <br /> q <br /> San Joa �� <br /> Environmental Health Department R <br /> E�,,..;t, - SITE <br /> i. 304 East Weber Avenue,3rd Floor Stockton, CA 95202 <br /> W <br /> (209)468-3449 Fax.(209)468-3433 Web: www.sjgov'.org/ehd A11C, I 1AITIC'ATION <br /> Well Permit ApplicationN-r Hsi,,"IT IV <br /> E[yVtRt.l TIII <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Kfk �w� L Fv <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instaIf the work descrlbed. This aPpllcatlon is made in compliance with San <br /> Joaquin County Development Title,Chapter 9 1 t 15.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL LocatlonJW141 Cross Street Assessors <br /> ty-�sc! ZIP �Parcei# x110 <br /> Owner_ 5�(� Address_ � f'' 31 20- <br /> 1 City-rL—c,+��---tip S�OZ Phone#cl0-y.37-MlC <br /> C-57 Contractor Woo wit d1i„q (p, Address 5'5G�i„en <br /> CC /++_a,� �� City 15'0 f'✓i zip � 1!Lic#71vd7 Phone# 7V7-37�/�f3vU <br /> Consultant/Sub Cntr 1 S En tp,nn�1Y7N� Address3 6 vrl{ p� ! <br /> "rf��., C �CgNt PY,ane#J (076 �a0oy <br /> GIS Coordinates:X <br /> Y Township Rane <br /> g Section <br /> W R PERF ED: <br /> '"EW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER” �{ <br /> ,]SOIL BORING# ) p DESTRUCTION (choose type below) <br /> 0 OVER-BORE. DIAMETER_, <br /> D PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING tOLJ OW STEM DIA,OF BOREHOLE " ': r! <br /> D EXTRACTION ©MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:Z <br /> D AIR HAMMERIDRIVEN CASING THICKNESS UO TYPE OF CASING: a STEEL D PVC <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL ?_o OTHER: <br /> 7REMIE E TO BE USED: AUGERS <br /> TYPD HOSE <br /> a AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes "o (NOTE: MAXIMU M.FIRE E-FALL DEPTH IS 30') <br /> D SOIL BORING a HAND AUGER GROUT SPECIFICATIONS rldf- U>rrt,P <br /> ©OTHER: rl OTHER- APPROX,BORING DEPTH 40' 'i`aBOLTED TRAFFIC BOX or D STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED nO (if YES,list specifications in comment section) <br /> ;I <br /> I� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT PR ENCROACHMENT PERMITS. ale <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> TIONS. <br /> 4 <br /> I hereby Certify that I have prepared this application and that the work will be drone in accord <br /> County Ord nances,Rules and Regulations,and all applicable California State taws. ante with San Joaquin <br /> Signed x �(,� // jj ` JJ <br /> TItMe1Company (Y4k5 i5 Y. -J ,fy.5 jF'10/'�,1 c-wu frN��i , LLj- <br /> Print Name 5{0 r — i Dafe$`IJr�O <br /> E <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: ��) „�„ / <br /> AA V1n <br /> WORT( PLAN DATED: e <br /> Application Accepted By p4 Date Issued A <br /> z O rea ra 2 <br /> Grout inspection By Date o Final Inspection By �� <br /> Destruction inspection By Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY; AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> i <br /> 35n1 •oma 13t;_o e�zY�a�, SR# <br /> C-57 W__-WAIVERR C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6122/04 <br /> 'f <br />