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man Joaquin County ...� <br /> Environmental Health DepartmentRoe ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202ATION <br /> '•c (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application 'SAN 2 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> PERF i/T�ikg"& p <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic i compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location t 1 4/o w. Lo u.tS c Ave_ Cross Street 0AJi0A/ City H0%4j1 C.Al Zip 9533 ea Parcel# .217 - .?La -.Z/ <br /> PROPERTY A44 <br /> Owner(A w.dtin•/ Address 101 ,Q4Ct Ss4 City my 2fS'-L-777T <br /> ygS�6S <br /> C-57 Contractor G ,. t Address '?Sc) /Ic..a f AcAc� City NA'/'-'cZ Zip�` --ic# Phone# ?AS X313- S$Oa <br /> co,,�ot,.wc 1J/iS 81,w/GS.t-..���rte ct.cic <br /> 4zS – <br /> Consultant/Sub Cntr CLjo,t,,� avC . Address_ Ste, #/ao Cityb+uv�Il c Lic# !!j _Phone# GS!8 <br /> GIS Coordinates:X 'Y Township !$ Range 7E Section 3-2, 3 1,3e, 2,7 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) X DESTRUCTION (choose type below) <br /> 0 SOIL BORING# gOVER-BORE. DIAMETER $ if /a <br /> a WELL# 0 PRESSURE GROUT <br /> o*Other GROUT SPECIFICATIONS <br /> COMMENTS: u.j-t I ove.. ✓�/1 `F- 8)c5 -. All 6ct1/5 S- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: u <br /> h1l✓—�- Ota► C/� `l 2 (�t�f/�L r CM* <br /> NOTE: OFFSITE BORINGS REQUIRE ACCE S AGREEM NT 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 r`"" <br /> County Ordinances, Rules and Re ul ions,and all applicable California State Laws. <br /> Signed x /C. Title/CompanC--!!�r.0 A�ck CI^S u r c � ,LwJ e- <br /> Print Name t^-�.s�., le f-fy Date /^.2,2 -,.2 oz)17 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 11 a6 tPgA, :.. A-t,4 �rt�1 An.i�4rcc <br /> WORK PLAN DATED: Nle- <br /> Application Accepted By L Date Issued l Area <br /> Grout Inspection By 4, vN.�r'c�-_ Date Z _j_1eb ?-- Final Inspection By (/( Date 3 O,�_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: �' L <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35-oZ X60.00 'S71 (0 (�' a'1'o� SR# OCA <br /> C-57_ WC -WAIVER— C-57 Letter of Authorization to sign permits Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />