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�o. '"�..�o San Joaquin County f�LS 2�r <br /> °i Environmental Health Department W L� <br /> " 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 J GATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd ()L 1 <br /> ENVIRONMENT LW IT IV <br /> Well Permit Application hLT}� <br /> PERMIT/SERVICE3 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards <br /> nof-San Joaquin County Environmental Health Department. <br /> WELL Locati'o'n E, M 1 t,1ILU�"Vp C Cross S�ttreet�u F�>J rA CitySTT � Zip SZAZ Assessors <br /> i 3q Z y o 1�- <br /> PROPERTY Fk_I ^ �t I nMl7 l 6 6b/ - /fl� • F �'L-q �� 7.3 ve <br /> Owner /' ress��4 Al, LI l i 2�n- City Phone# N� <br /> C•57 Contractor(P0 Un LbEicr ..1� Address�K-O .,JL 1�u • Cityltln. n,3EZIp sS3Lic# '�Sl��hone# `I2-S' 3t3-S8� <br /> /� othU,ESio r`�Q,/,r�i oo'g onn!e <br /> Consultant)Sub CntrFr.rS2/ oG�'cfLAa-e+}�ddress S-IT�. 2Zo CityQdL'Cn� Lic#Q1• "phone# S 16 -35'0 'rS I <br /> GIS Coordinates:X (0 5- ,os''Y Z Township 1 Range gL F Section 2,0 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (_CPT, OPROB ,HYDROPUNCH,HAND-AUGER,OTHER`) E DESTRUCTION (choose type below) <br /> SOIL BORING#�(7 -( 'SrSc�-3 S(�-�I SCC'7�-S <br /> DOVER-BORE. DIAMETER <br /> ()*Other <br /> a WELL# Sy6-, SSURE GROUT <br /> ILQ.,IISC9-4 / G RPROET SPEC FFICAATIONS�'7 <br /> COMMENTS: SCG-_? Jry" ""�'`S`�_I t•`.,J� � lt�^ � 5^l�( � <br /> TYPE OF WELLI41 P1 INSTALLATION TYPE 1A CONSTRUCTION SPECIFICATIONS <br /> o MONITORING E HOLLOW STEM DIA.OF BOREHOLEr A p MULTIPLE CASINGS E MULTI-LEVEL WELL CASING DIA:_-L �A <br /> o EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: n STEEL a PVC a OTHER: <br /> E VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL '� TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> E AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FRE{E-FALL DEPTH IS 30') <br /> a SOIL BORING E HAND AUGER GROUT SPECIFICATIONS jC1 �i VZIVYti�A�" <br /> p OTHER:_D OTHER APPROX.BORING DEPTH_ Ff�10 p BOLTED TRAFFIC BOX or p 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 Or nances, Rules an Reg tions,and all applicable California State Laws. <br /> X-6 �,�),. I Title/Company /'S .en <br /> Print Name <br /> DEPARTMENT USE ONcLY/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: (A 3 l YM' wri�/L� JT . SItc . <br /> WORK PLAN DATED: to l l 16 (a <br /> Application Accepted By .rte Date Issued IF Area Y y <br /> Grout Inspection By mLL,,C� (- t 0 Date IDIal 10 Final Inspection By Date <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 I SERVICE REQUEST# INVOICE <br /> OT) CII � P-3 -,-)— !o /G 0 sR# � ,5� <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 />