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San Joaquin County <br /> Environmental Health DepartmennnnnnnnnVO 4 2p\p SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 N 1 ATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehdJP�NMyN(KNIT IV <br /> Well Permit Application oqw' \jISERVI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p <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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1111I15.3 and the Standards <br /> �off San Joaquin County Environmental Health gDepartment. <br /> 15boo s, rluf{4� IW . V , IA Gity Zip 15331 <br /> Assessors <br /> SceI#S 19/v-aoa 79 <br /> WELL Locatllo""1�n (11 Cross Street / � U� p rh GV 7 T1?(� <br /> PROPERTY 1.1 LI 06Dk Address (41'v 1S (✓-u� {0L VJ l <br /> 5660 5. { /�, ciry�1/ zip 3D Phoria# <br /> C-57 Contractor is ST fb�^11LL�:hy AlIdd^ress ''7 u ?/' Lr^s� S�. City�J' Afuj Zip3S77C Uc#YU1134 Phone#'h3o-�Y 1414 <br /> Consultant/Sub Cntr 51 fok(.'morin 14f8jj kAdtlr3essy&M I!IMPI C Dig# Ci�UtM PLwic#K55-�YPhone# _ <br /> GIS Coordinates:X ,Y .Township Range - Section �X-o�1t!O I <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type.below) <br /> 0 SOIL BORING# JPOVER-BORE. DIAMETER <br /> 0 WELL# ,$PRESSURE GROUT L I <br /> 1]*Other M / y� GROUT SPECIFICATIONS 1`401 Lklsk I <br /> COMMENTSAW_I Moro-I ) IhW Z1 f4 t-MW=�I I'r�'S/�l(/G� iflw-7 Ir rl�W-1�0 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (See aAitvrtU ✓ub{e� <br /> .MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LE L WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: I]STEEL a PVC g OTHER: <br /> 0 VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AURFR GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER— _.-_ APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a 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 Ordinal Rules and Regulations,and all applicable California tate Laws. <br /> Signed x y Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 S 60 C) (cr — a2 a <br /> WORK PLAN DATED: /L/A- <br /> Application Accepted ByA.nt�[� Date Issued Z�12.,1 U Area <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By �lN-g-Q�, Date �) O <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY:. AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3SoZ yoS ao Zt /2116 SR# <br /> C-57_,WC---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/04 <br />