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San Joaquin County �, E COPY <br /> � % Environmental Health Department I ���/ ��r - I�TE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 1 �� � -' J M>� CATION <br /> (209) 468-3449 Fax : (209) 468 -3433 Web : www.sigov.org/ehd L�07UNIT IV <br /> Well Permit Application <br /> L;VVIr t 11r4 . f I ' if-ALIT; <br /> NON-REFUNDABLE 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 h1' 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 .7 1S N - NUtoTF '4, ST. Cross Street F o 2P. -r . City Assessors <br /> w_��Zic� cp 95202 Parcel# <br /> PROPERTY <br /> Owner 'VINCE ER4 RllT Address P.o. E\ux (_� O \ (� 1 City STo�_ a Zip 95202 Phone#t7.09 ) 956- 9010 <br /> C-57 ContractorDHSS-ACIn ' TIiTN • Address ?632011F C= CC. E Cityizet o Zip 0v574LUc# 7i75rc Phone# [9161Lek -5 (v ll <br /> AovANcE�D Gsv - «Mcic+vA <br /> Consultant / Sub Cntr Nyrp H E N IA Address ez-r [ HAw pit) CityaMC> m. Lic# Phone#- zo° )467 - 1uo6 <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> LNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') flDESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE. DIAMETER <br /> ;R WELL # Mw - 1u Mw - 11 .51 w -L7 0 PRESSURE GROUT <br /> 0 `Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [MONITORING $ HOLLOW STEM DIA. OF BOREHOLE R „ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _2 _ <br /> n EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS zk - e 40TYPE OF CASING: 0 STEEL gPVC 0 OTHER: <br /> VAPOR as ge9W -.^) 76` TREMIE w � y� <br /> 8 0 MUD ROTARY DEPTH OF GROUT SFAL�.C11,,.•., n TREMIE TYPE TO BE USED: `AUGERS p HOSE <br /> n AIR SPARGE/ OZONE p PUSH POINT (GP or CPT) GROUT SEAL PUMPED: RYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS Po?.T1 ntt0 _i-YP E II- <br /> 0 OTHER:.0 OTHER APPROX. BORING DEPTHb yy� "w o1a°oHwWx 7t BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDWNA (if YES, list specifications in comment section) <br /> COMMENTS : P LE A S F a° FpEQ To ' /cK Al AN Eb 71 7? C-.r <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 Ordinances, Rules and Regulations, and all applicable California State Laws . <br /> Signed � �_ Title/Companyr�TAV F sc E p4TI 1ADIfLAN ` EDC G -N �rp �(V M �NTAI. <br /> Print Name McyI %( I PF: Date_:� / t C0 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : Vol t > W Uw JI � v Tt <br /> WORK PLAN DATED :/A� <br /> Application Accepted By � L.n,ALuJITN- Date Issued Area =>4L ( <br /> _ff <br /> Grout Inspection By_ Dale Ti�.'V`1 Final Inspection By Date I y <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> ECODESFEEINFO AMOUNTREMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> a°l . oV 'Y4-A- '0 255'kS AD- 3l L(o } SR# OD461 B$1 <br /> C-57`h WC e$ -WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />