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RE,...,, ' V E D SEP U 1 Luu.r <br /> p San Joaquin County <br /> x Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 952JCJEffIGATION <br /> (209)468-3449 Fax: (249)468-3433 Web: wwwsjgov.org/e NIT IV <br /> Well Permit Application SEP - 7 2005 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS N/(RQNV f EW HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described a in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental a �ell'aiitJM� <br /> WELL Locatlonz�'�tocl L.oO";s RCity ai Cross Street W on C ��yc�Jr� zipo6LpS Assessors � <br /> ParcelA`• 1-1`�-��� <br /> PROPERTY Vgl�^zf °15252 <br /> Owner W'\P r( . Address k0 W. ' kk"_IVAS Q gk City S x.. S Zips, Phone*_Z 12- - �1�{� <br /> C-57 Contractor SS Address ZZo N , �cs� City Oad1L9+ Zip IS�_1 b Lich ,o S30 -�68 z <br /> City m0�I1-00 Lic* — Phone# 15ZZ- q I I Q <br /> GIS Coordinates:X Y Township______ Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING CPT OPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTR TION (choose type below) <br /> IDSOIL BORING>f c-P S l - CP'j 10 \ Q OVER-BORE. IAMETER <br /> Q WELL Q PRESSURE GR T <br /> Q•Other GROUT SPECIFICATI S <br /> COMMENTS: S l. � � <br /> - �"� @ `� l X- 0 S 3 - S -O <br /> Opy <br /> TYPE OF WEL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: _ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE it PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: n OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q 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 finances, les an Regulations,and all applicable California State Laws. <br /> Signed x Tiue/Company PK ,�c_ _,__//fir• _ � _. <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 9 9 Loomis -R.o a <br /> WORK PLAN DATED:_ A 12r;J I R. 20 O 5 <br /> Application Accepted By - V v4"e Date Issued 9- 8 -D S Area 14. 9 <br /> Grout Inspection By Date //-3 ,S' Final Inspection By L&& �' i��fl�ate /I-3 -0 S__ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: S CePT- '2 - - -S- -7 s -9-�, <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK>x REC'D BY DATE PERMIT/SERVICE REQUEST* INVOICE <br /> iso f 2'79 ao 3L 8. o o sR# D a 4 3 8 51 <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 />