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San Joaquin County <br /> •.a <br /> Environmental Health Department _ SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA � ������L j ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov ofh `-� <br /> r �- UNIT IV <br /> tFoRt Y ., <br /> Well Permit Application 'IEp - i (_ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATES r r,. <br /> 1OE VIENT I-!E-ALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ O�Wo jade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmen a Heath Department. <br /> Assessors <br /> WELL Location //9(a w. Le.r,s .4.e Cross Street Wy,&L City .4-1A,uAte,4 Zip /I'VI(o Parcel# .?/9-?46- ?/ <br /> PROPERTY K �"w's C y�F•��Sb7tt <br /> Owner —.4--9r- Address '1401/D/ M—F-r X / <br /> City .T! <br /> C Zip ftl Phone# 4 <br /> C-57 Contractor V 10L&,u t)C / Address_2//p An►A.Rs Ave Cit S ia#�C 5qZ Phone# 5b-SL t-74 74 <br /> Y�.A'Zip is! 7rM <br /> ^rr.#Gee/z <br /> Consultan /Sub Cntr�y,rs r r,r, Address .tft. /so City .// Lic# Phone#I�fj)eV>T.200 <br /> GIS Coordinates:X Y Township /s Range 7E Section 32,.7 ?a 2'? <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING (CPT, EOPROBE HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# (��,(' (/O.7 0 OVER-BORE. DIAMETER <br /> WELL# U PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z~ MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL 0 PVC Q OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS U HOSE <br /> a AIR SPARGE/OZONE A PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 9-f 4 Ge"w _'04 rr►//iv s o <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH If Q BOLTED TRAFFIC BOX or a STOV IPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in c ent tion) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PETS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> )_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin--,e <br /> County Ordina ces, Rules and Regulat' ns, and all applicable California State Laws. <br /> Signed x Title/Company Cw•n,o/„yuc. Ln� Z'u� ` <br /> Print Name_ G.�.ty R_ /4UZ_kt . Date p''.?/ <br /> DEPARTMENT USE ONLY - <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I 1 (J <br /> WORK PLAN DATED:_ $ A�l3 <br /> Application Accepted By Date Issued m4 t♦ 1041; Are 6 L L4 <br /> Grout Inspection By ���ed[ �.`.. Date C t O Final Inspection By��ws4,.,c4,, Datea <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 01 t p <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 So 1 •00 0001 <br /> o 7-t-5- Alr •oo Cb t�f 9 rt o,6 SR# <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 />