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San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 IIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> *P0 Well Permit Application AFJ 9' ,57 <br /> CNV/„CUIF 0 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED //Eq T,KQN/. /E�QUNT Y <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 compl nCe4vi/tl r�H T <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /� — i Assessors ��_` <br /> WELL Location 155Y0 SouttA 1 A� Cross Street J Stfre} City _Zip _Parcel# <br /> PROPE TY r' rf0 7f QQ 55A&00 UCO-L a 2t� <br /> Owner Address lus"byri-L tf tat- City 1�N Ziippb-v��� Phone# 17S'0I10-63o(� <br /> C-57 Contractor &A:hc & Address &y-0?M!:tl7��ll ILCiity Zvt�c - Lic#jjj%_Phone# �� ^63 -0 <br /> 69 <br /> Consultant/Sub Cntr S�Znt- Address c't Lic#6S'(AM Phone# 9/L:ffi0Y00 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> ,,SOIL BORING# a OVER-BORE. DIAMETER <br /> LL# &ha . rAW a PRESSURE GROUT <br /> SOIL <br /> tther GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIOtj SPECIFICATIONS <br /> ^MONITORING HOLLOW STEM DIA.OF BOREHOLE 8,7 <br /> 3 a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:z'7 <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL rVC p OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL3T_TREMIE TYPE TO BE USED: AUGERS p HOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes bQ4o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS en-wo- <br /> OTHER: fl OTHER APPROX.BORING DEPTH ISi�� DCBOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /A (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 Ordi ances, Rues and Regulations,and all applicable California State Laws. <br /> Signed x t� dL`_ Title/Company rJ;�'dc 15f 1 CA2 <br /> Print Name D6'1 wriV4 Date <br /> DEPARTMENT USE ONLY/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 00 t ( a0 <br /> WORK PLAN DATED: ��✓� OS Q / <br /> Applica�ion ccepted By O Date Issued ! !�-3 /�-s Area <br /> Groinlh pe�tion By Date t3 Final Inspection By Date g�y�d fo <br /> Destruction Inspection By / Date <br /> COMMENTS/CONDITIONS: r&t t n N C M r 9 f 0 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> sR# �o <br /> C-57_ W(----WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />