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San Joaquin County u llE <br /> Environmental Health Department "9 � �t ffiE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 JAN 1 4 ^TIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org� ¢ UNIT IV <br /> Well Permit Application tAVIRONMENTHEALIN <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 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 /> WELL Location ,- '" 1555D5, 11v1AAfU/, Cross Street ✓• *'Od City L{Nr}O Assessors <br /> Zip 5 CJD Parcell r !6-190- <br /> PROPERTy- ,7 /J� / '/ <br /> ,Owner 7�Drs!f r/D ''11 Address 15550 5, IIWIwl(p, City L�t{�+mo zip Phone#L D�/-7S� Sfy2� <br /> CS7 Contractor RSl bG+�114 G Address N. /I I rt�Clty�$�P+ zip-57s�1% Uc#Kv1a34 Phone#S?&'LC8' 1424 <br /> Consuhant/Sub Cntr5Tis' 5l-n A1Yy/" p�' � (antom No.IC a.V, C`ty' C4Ka'4% L�e' 95(osZ Phone#_53a-(o7(-ao%z� [I <br /> V}roc, � dres I / i <br /> .GIS Coordinates:X ,Y Township Range 1 ii ''A'+rM II ` (Section �67 <br /> WORK TO BE PERFORMED: (KE LA �A�M <br /> n NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> 0 SOIL BORING# ,OVER-BORE. DIAMETER <br /> 0 WELL# IFPRESSURE GROUT <br /> O.OtherrM - GROUT SPECIFICATIONS f <br /> - COMMENTS:_Mux-I mla <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING n HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA'____ <br /> n EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: n STEEL 0 PVC 0 OTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> .a OTHER: n OTHER APPROXI BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> .,..,.OL'CTOR CASING PROPOSED Qi YES,iiai speci5ceiions 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 OrdinanRul /es and Regulations,and all applicable California State Laws. <br /> Signed <br /> c f <br /> Signed x' Title/Company ( I/ <br /> Print Name 5� Date lZal-Oy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Sh O o I-6 n IF, 1 f c.cf- <br /> WORK PLAN DATED:_ A)A <br /> Application Accepted By U�,�C C-1i Date Issued_ I"2��(U Area '797 <br /> Grout Inspection By Date Final I�spe ion y Date <br /> -Destruction Inspection By Ayvp-�, Date„L �D I D } 2- i <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED .CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3502 S`(0stoo -Zj3r_ta z / fd SR# Sct3-3. <br /> C-57_ WC—WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ I <br /> EHD 29-02-001 <br /> 622/04 <br /> 1 <br /> S <br />