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San Joaquin County <br /> Environmental Health Department— SITE <br /> '104 East Weber Avenue, 3rd Floor, Stockton, CA 9520"i,`----f C",N-, �:-Mfl-T,,IGATION <br /> -3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> (209) .3 ---UNIT IV <br /> Well Permit Application F i7 Y7, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describeqFJ,*; 411" anion <br /> ti pnq�,. n compliance with San <br /> e <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heal epia�' e <br /> 5, Atp'� I -L Assessors <br /> WELL Location '1,2 73 (1 Cross Street Z 4-4, /(V city 1"(Ii- <br /> COO iu,1-e eA zip—Parcel# <br /> Owner 2-1- <br /> PROPoERTY/,' <br /> e L400 LIA Address K>'SO �4�IA44 V Cit Zip Phone# <br /> C-57 Contractor V-t Address 100 "4 cityl'51ACAj Zip Lic# VOY Phone# V0 17"1 17— Y4610 <br /> Consultant/Sub Cntr ele I#V Al A Address OV'L-' City 54kIlLf Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL if BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ESTRUCTION (choose 7pelow) <br /> 0 SOIL BORING I VrOVER-BORE. DIAMETER_ 110 <br /> a WELL# in PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: &I'-i-11 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AMONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 1*VC a OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL —TREMlE TYPE TO BE USED: OAUGERS a HOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: 0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or�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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> "Y rr Jft , <br /> Signedx Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: I/ Al <br /> -7 <br /> Application Accepted By. f"Z'Vjl� Date Issued Area <br /> -Z Final Inspection By <br /> Grout Inspection B Dale 114' Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS:" is LZAZET- 7zr T57 s a-C <br /> ACCOUNTING ONLY: AID# I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> LZq(92 o • 12. /6) SR# <br /> C-57— WC=WAIVEP C-57 Letter of Authorizati,:Vto sign permit Encroachment doc <br /> fi <br /> EHD29-02-001 1-2vt P <br /> e�,c V-vy tq-cz <br /> 6/22/04 <br /> �� C roo-F S6-A5 (w h'c,� 43 5f'%[ J'S44 ?WCf'1 V;evje# <br />