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i f <br /> USan Joaquin County ���� 1 <br /> Environmental Health Department *DFE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 JAN 1 4 ATIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.or iUNIT IV <br /> Well Permit Application VOIRONMENTHEAiTT <br /> PERMIT/SERVICES <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 I <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 15 55D 5, I�vIA,�Rd, Gross Street 3: Sfii - Ci L`4�r)° ZPROPI s 3� P Sce 19G-19o- l <br /> sors <br /> WELL Location �7 C" / n/ 'h/ v <br /> Owner ER 7�Dra! r/O . Address ISs..v 7� IIrvrt l(p, Cily .�l''t�010 Zip -7 <br /> '1 f r / 5330 Phone#�O CI- 5� -gVZr <br /> C-57Contractor.aSi b+I�4� A��ddLLrpeQs-�ss"Lu At. �y+J�'. Cltyl�d"Si- ,,� Zipg51% User°1134 Phone#S3W,4U 1421 <br /> Consultant/Sub Cntr 5TR 5 &y11D>\M�.'"� res3r� (Qmom Ppk 01 �Ciiyf/ Lic# IS(oS2Phone# 530-06-206Zo <br /> ..GIS Coordinates:X - Y ;Township - - Range)) CAA�I IS,,e�cDtion <br /> WORK TO BE PERFORMED: - ISL� CtY1"A �60 - <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p,DESTRUCTION (choose type below) <br /> a SOIL BORING# /a OVER-BORE. DIAMETER <br /> DWELL# . - &PRESSURE GROUT <br /> a*Other �yi �7 � p ,�1 - GROUT SPECIFICATIONS <br /> COMMENTS: Mwo-I I IIA_o_/ Mtdo-� /rtU/�,ISI iA�-// 17-ZG;_ _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC a OTHER: - <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes r a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: - B 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan s Rules and Regulations, and all applicable California/State Laws. c <br /> Signed x' Title/Company (, � ��rc s <br /> Print Name 5 I. •O _ Date IZ�I-Oy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 Q I-6n 1.11 w <br /> WORK PLAN DATED: A I A <br /> Application Accepted By ���.a An^L-vr�.- Date Issued__ 7i 112-bo Area <br /> Grout Inspection By Date -: Final Inspection By —Date— <br /> Destruction <br /> ateDestruction Inspection By Date - <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAC# - <br /> PE CODES . FEE INFO AMOUNT REMITrED .CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 50 2- $'�(e'stoo -ZI3-CIt SR# 5c33 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 - - - <br /> qtl <br />