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USan Joaquin County <br /> Environmental Health Department 2p�p - SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 \PN 1 Q T ATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd" KNIT IV <br /> Well Permit Application �Np�RMMISERV�C <br /> -NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> ,LL C1 Assessors q�_�� <br /> WELL Location ISboo s, Hty'�4� �� Cross Street J✓1. Ciry _Zfp`15337) Parcel# 1// 71 <br /> PROPERTY n I '•- 1� L I 0�� / y1/',, \l <br /> Owner IJq UAw W6b1 Address 15b� 5� �"FU r"�, Ciry �-WI6!lt2 Zip'15 36-Ph1ne# jM� 1BZ—v3� ? <br /> C-57 Contractor Q ST �W11'w+� Address -llu P. cics " SJ-• Clty�laj(bj Zip13'77C L1c# u1334 Phone#530-uY 141} <br /> Consultant l Sub Cntr S1/MI'S neinn Add 3330&VM Prwtl' D�,#55$i�LA1 Lw#(— SG87 Phene#S�a�� <br /> GIS Coordinates:X ,.Y ,Township Range Section G76_�6 y <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER? DESTRUCTION (choose type below) <br /> a SOIL BORING# R;BORE, DIAMETER <br /> u WELL# _ RES <br /> SURE GROUT I� 1. — <br /> 0.Other GROUT SPECIFICATIONS Nu71 (9dti^� <br /> r, COMMENTS:Mw-Two-1 1 MW14ft-�MWA MW-5MV-h Mw-1 Mw)o <br /> r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (S e adrdgj <br /> 1 .MONITORING D HOLLOW STEM DIA OF BOREHOLE_ p MULTIPLE CASINGS 0 MULTI-L L WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROLrT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AU,FR GROUT SPECIFICATIONS <br /> 0 OTHER: n'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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina Rules and Regulations,and all applicable California/}(tate Laws. < <br /> Signed-x Title/Company leo 10S;51- <br /> Print Name 57 1 IA�P'/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ A (C4 (Z� <br /> WORK PLAN DATED: ' /VII <br /> Application Accepted By - ((j�;w AAACI 1 Date Issued -2. I Z'I d Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By _ Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> 35oZ $ yos eD zt Gtrz l21io SR# 5 Dk33Z <br /> C-57 .— WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-101 <br /> 66/22/04 <br /> y <br />