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yn a"pl+y. 0 <br /> San Joaquin County <br /> Environmental Health Department <br /> 1 304 East Weber Avenue,3rd Floor,Stockton, CA 95202 2005 APR�� ja� <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd S A N 1 C:1 o LUNI(TLM Y <br /> L Foga Well Permit Application HEA�YIROLPAR i4MEN IML <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 Mw-; <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors sw-370-v% <br /> Mkl4nleY z41-4o0 - n�J•t <br /> WELLLocatlon Ye{�s-4t IWC Cross Street 1wc City Lw}Lore Zip7S33o Parcel# 'L', 9y w+M/-3 <br /> Y7787 S 1�tenN+cy Rol. <br /> L41-4100-I(r FAW-y� <br /> PROPERTYiMl-SIO-07 . W-e' <br /> Owner 'Tc1J Address PO- ibox 310 City(o.4t.a-ee zip1SSW Phon lk°-798 Z-15-4 Y <br /> C-57 Contractor SPac.4eu.n 5M ddress2-%5 u;+w>+ Oo• City i!,IL Zip4SAe Lic# Phone og�k 4L6-8712 <br /> Consultant/Sub Cntr E.w)1660) 2.Jf. Address 2S%O u-Tcwey eta iry My I-c# Phone v 835'-OG/O <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> OEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a`Other / W% <br /> ani <br /> SPECIFICATIONS <br /> COMMENTS: C <� t O e6 (S '.) View W-(" Wni 6V61e1/3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> *MONITORING SHOLLOW STEM DIA.OF BOREHOLEJ%^. a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL %PVC B OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL O-7 I TREMIE TYPE TO BE USED: ICAUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes VNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS New k C-4--dh 3 <br /> Q <br /> OTHER:_B OTHER APPROX.BORING DEPTH 74 ' U BOLTED TRAFFIC BOX or %STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N8 (if YES,list specifications in comment section) <br /> COMMENTS: We o(E(e'1 wnd tOCdLN1; g,ezeey of lay RW a.C-S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have r pared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances Ru d ulations, and all applicable California State Laws. C .f <br /> Signed x Title/Company .f&9 GNr�O w'S1t //+-w 6 r-o --rw. <br /> Print Name <br /> C!ra..J -ol Date y.jfyy( <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: lo-.-e W c{c f rV� PAM:!�41y <br /> WORK PLAN DATED: Iz(, 1__ - 112140.5—. �I � <br /> Application Accepted By 12� Data Issued U 1 /0 S Area 6 2.f <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 REMITTEDCHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a°lot �q•oo o�(s�sS3 kA4 �-- SR# Zo6S <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 />