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P,. V�I.H F IL E CO P� man Joaquin County <br /> Q <br /> ,o A. .. co P (��,� <br /> Environmental Health De artmentnSITE <br /> "r `� '{ 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 '-�IIl1TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ek@V � 6 2OO UNIT IV <br /> 5 <br /> 4�,FOR� Well Permit Application EfMpRONM,ENT HEALTH <br /> LE <br /> NON-REFUNDABPERMIT EXPIRES 1 YEAR FROM DATE ISSUEBRMIT SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct arxUor instaN the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter <br /> I 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. i <br /> Assessors <br /> WELL Location-67r L AYE S� Cross Street�/�t(;5 City G��--ova Zip �r7_ �Z5 Parcel <br /> PROPE TY ._tt C'k_�^ �T f+Ie-'-0(.S-,�r!Ct <br /> Owner Address47.6-75 5-,Aii^(5-LCityS 14'— Zip ")IZ6 Phone#22q���(��-03313 <br /> C-57 Contractor CCLS t1lafi Address,-A � Citv� ZiA Lic# Phoned'1110• <br /> Consultant I Sub Cntr Address City Liar Phone# <br /> GIS Coordinates:X3-r5-7 S-1,� ,Yf Zl'I Z�33,5" ,Township^ Range Section_ <br /> WORK TO BE PERFORMED: <br /> IEW ORING (CPT P HYD OPUNC'H,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> IORINGS_ eOLB <br /> N 3. 1Cty�ej0 OVER-BORE. DIAMETER <br /> OWELL# I 0 PRESSURE GROUT <br /> a•Ottw GROUT SPECIFICATIONS <br /> COMMENTS: 501\ I n�,o c 10 f S o�-t� ° 3� I 0►uaJ.ad'. Vt b <br /> .TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I f <br /> %21�10NITORING OOLLOW STEM DIA.OFBOREHOLEjgtj 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA.-%%W+1 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5ch f0 TYPE OF CASING: Q STEEL )KPVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 420 - e TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ,gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS bend 1-Fo. C ` <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH Ibo ke-L a BOLTED TRAFFIC BOX or STOVE PIPE(5i) <br /> CONDUCTOR CASING PROPOSED 14C) (d YES, specifications in comment section) <br /> COMMENTS: Screey\ 1r)4eXya� Mhci"d &5 W1� l2e_ e SI C W��� Q_'&-CSLiS <br /> afp-lax 65 - i•- b?. <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 O,tdlpp i Rulqs Arid Regul ' s, and all applicable California State Laws. 11 j <br /> Signed x _ - Title/Company <br /> Print Name_ i �/ -- o d - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _�_� (4 e'�f <br /> WORK PLAN DATED: A- c <br /> Application Accepted Date Issued J Area <br /> Grout Inspection By Date // -1B� Y Final Inspection By ate JI-Ig •i2 <br /> Destruction Inspection By Date II <br /> COMMENTS/CONDITIONS: L lY) om+ �''� 4< <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> -An b2 1 _�l (.5V3 11-17-Q5 SR# U 6 (:::7 <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 />