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San Joaquin County <br /> l J is <br /> Environmental Health Department _ SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,a"45202:' `- ` � SITE <br /> _..,r <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgovorg%ehd" UNIT IV <br /> Well Permit Application <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 9-111115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> a"' S C4� lt� Cross Street { w(w City P S <br /> Assessors <br /> rce <br /> WELL Location OU� �.�r< C S�'o(,k tWt Zi a0(, �fo5- o3o-/n <br /> PROPERTY <br /> Owner TjVK0UUj i 04 Address13aD S. Von �V.,{� City t� ave Zi �SZC <br /> G U 5/ Pp_�Phon/e# x(0-453-55h- <br /> C-57 Contractorl, h fo/ Address3$ I -1 RG,j ?.")---city TU64 (i Zip 154I(I Lica 61,g6 d Phone# u80474-5YS5 <br /> n pry,i#sSU ty Ib <br /> Consultant/Sub Cntr�r�rSrHviroKvlVnt/FtX,��AddresSC�-c+� City ParK Lic# Phone#S3U-(o7(p-2D(oZ <br /> GIS Coordinates:X —'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> `(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> a SOIL BORING#, 0 OVER-BORE. DIAMETER <br /> 'WELL#ftiW-'?,i�1v✓-k, rl1'L%-I f f+lam-I 111V-Ij <br /> n"Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSt� C{G��� l��IL✓'O fl <br /> 'MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL bTVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No,(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 1'lP'-'fi <br /> a OTHER:)ETHER 50�1 c C APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> .11 QONDUCTO CASING PROPypSED (if YES,list specifications in comment section) <br /> COMMENTS: �� W. (��CX dic(cjl'reyo t2l tL � S��Ci a�(4�S 111lr f <br /> Gql UL - i /-Q/tW, 96 `to s% <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 Ordiinnan ,e ,Rules and Regulations,and all applicable California State Laws. f <br /> qL <br /> Signed x �(h@ �uU�` �/ Title/Company()-eo .}i$f — 54"x L3 Ghyiro✓t /j^f, <br /> Print Name 5Go'f't- Date 11-Z7-97 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �C/�l� s. C_i"-Ie-e � /0' ,•� <br /> WORK PLAN DATED(:_ %%115-16' _ <br /> Application Accepted By "Z�� y -x Date Issued 1�G�/a / Area 7 y <br /> Grout Inspection By /�,.r�n ,w�J Date L I t�tLFinal Inspection By �ate <br /> Destruction Inspection By Date <br /> COMMENTS I 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 /> EHD 29-02-001 <br /> 6/22/04 <br />