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HLL C <br /> an Joaquin County. <br /> Environmental Health Department o SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd IV <br /> DEC <br /> Well Permit Application 1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVInONhIENr <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thi' (kt�1Fad�AL bMpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and//the Standards of San JJoa in County Environmental Health Department. <br /> �p �3 t!/it!�� Gfr►a � 7 Assessors <br /> WELL Location O _, Cross Street ( _��/P�!'�_City t Pa Zip 953ogParcel#201 �50•l y <br /> PROPE"T /rZ7-Abr..e �� -15 <br /> Owner­4Ce,, yL .,, Zkddress '��City Zip hone# " /L <br /> C-57 Contractor v +N/ b,- l Address too 54""54'(V .7 City-1�11+br Zip4M1/Lic#7Z"/0 Phone# 116-777-Y100 <br /> '''' <br /> Consultant/Sub Cntrla/Pact-1C� 4-Af$#-,Address3910 W. �Lic# Phone#"-23If-77ZZ <br /> GIS Coordinates:X Y Township Range L Section 16 <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,G OPRO ,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> SOIL BORING# 1-0 OVER-BORE. DIAMETER <br /> []WELL# a PRESSURE GROUT ff / <br /> []"Other , [[ GROUT SPECIFICATIONS 6"1%14xS l"Z-f-y <br /> COMMENTS: Pfbbe,. 4-a l5 - Z-o bojorel S6t1�1"a�c, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING a HOLLOW STEM DIA.OF BOREHOLE- MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC a OTHER: <br /> []VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> []AIR SPARGE/OZONE XPUSH POINT 6or CPT)GROUT SEAL PUMPED: a Yes roo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING o HAND AUGER GROUT SPECIFICATIONS_f1�� IJt.I' 4 V%i� s hots y <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH 15'-2-o/ a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or ces, Rules and eg tions, and all applicable California State Laws. I� <br /> Signedx GI/ _ 1 Q I Title/Company S4wff ,"If0� &JkA <br /> Print Name I v�L- Zy%-7 L)a SN�ll�w DateZ./I$/06 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r <br /> WORK PLAN DATED: ,6 b <br /> Application Accepted By Date Issued-12 [ 0 46 Area Oki <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <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 /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> -ov <br /> EHD 29-02-001 <br /> 6/22/04 <br />