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F <br /> San Joaquin County <br /> `.- Environmental Health Department ITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 JAN 1 4 20161ITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.ow/1 h( ONMENT HEALVIT IV <br /> Well Permit Application PERMIT/SERVICIES <br /> ` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> _f 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 /> {{ ''ff 1 /� � -{ G Assessors <br /> ` LWELLLocatlon 155`I� rl'�'�(A'1'S_ IW 15-';5) S, <br /> Street( J /f5��red CiNty,, Lk kwo Zip rS <br /> Par <br /> I F vZ <br /> ( - PROPERT ,p P(O .Address �5.7--1JS, �d/1 +`!A ``/'V �/ <br /> Owner \\Y� 7� C City_&I ,,,1� ,I, ZIp�jZPhorle# uZD-1-75/- `/y2(, <br /> , CS7ConVedor1`S* uri���1� <br /> Address ,�/ LUS)'J�, CitytAj(&"A ZipySll6 UaM'134 Phone#53o-(06Y-1424 <br /> l I ,,: I 4�550 � nPlnp q � L <br /> s.= ConaultaM/Sub CnV�"�>'Z14y5 hu'�ron✓/�ry�lA dess..353ll �iIN1Ph)1 Pic idly � Uc# 5 hone# <br /> ;'.GIS Coordinates:X ,YTownship - Range Section <br /> ut <br /> l� i WORK TO BE PERFORMED: <br /> f0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) , <br /> -'a SOIL BORING# - XOVER-BORE. .DIAMETER -_ <br /> 'g WELL# WRESSURE GROUT . I <br /> '0.Other - - - GROUT SPECIFICATIONS rift/ (Lw <br /> COMMENTS: l%W_ -- <br /> { <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASINO: D STEEL 0 PVC BOTHER: <br /> -'- D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE j <br /> 0 AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D.No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX 1 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 /> thereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin ares Rules and Regulations,and all applicable California State Laws. j <br /> Signed z �L19' l-..1/1 (R� - Title/Company <br /> Print Name �(n�+- IJ i 4i n�'1 Date I2- 1-V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I 'gL D o f rnn �rtw e� <br /> WORK PLAN DATED: 1\)A <br /> Application Accepted By. LAYln A^C1 - Date Issued 'Z� I�I C �Area <br /> Grout Inspection By Date. Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> M <br /> ONLY:- -AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# S �(333 <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 />