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o .u ,...;an Joaquin County <br /> Environmental Health Department {� rSITE <br /> H 600 E. Main Street, Stockton,CA 95202-302�b ����1hL"J' IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.SJ90v UNIT IV <br /> • q�/FORN� Well Permit Application ASR 2 0 2D1a <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE,VMRROWENTT��RyEEr��AA(L(�TH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descri l�P."me t in comp/'r.20with 3�n <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of S n Joaquin County Environm n ��+��a1tH department. <br /> .fZe �;Ti.-c�C . S � / Assessors 103A.-00i <br /> WELL Location� N�vv D!. Cross Street i i l l ! 1-CrnCity .J7a[lx Ten Zip l s� Parcel# t oq o16 <br /> PROPERTY / <br /> Owner�r�> s�SToc�itl� <br /> Address 2504 /ll VV�l Ciry STCcMfcn Zip 95Zt:1fZPhone �' 4 -y7yQ <br /> C-57 Contractor Fi54 Fn Vi LOA MYA(Address 3993hcf�'s cL CityVall [•-'zip 5252Lic# Phone�C 76 9900 <br /> �p 1 Sze1 G <br /> Consultant/Sub Cntreon�dr��.r rPc�, Address � Flan(•t w>fT�/: Ciiarcc # PhonWI�ZO4Z,3�f-Q.s�p <br /> GIS Coordinates:X F>iL2-�y9-aA ,Y LI 6 LI 266.0 y ,Township l Range Section l '*. <br /> 3G G 'tlrT�.eG.e <br /> WORK TO BE PERF <br /> p NEW WELL/ QRIN (CPT, EOPROBE)HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> Other U fc.laa("r•urA[. w-.t-[r S.-. rl, +T lace r'art GROUT SPECIFICATIONS 3ylb S-IOjrtlr.�c7�!- <br /> COMMENTS: �F 'r it Zi, a A- bL-la• ri-[. 1 3vrl��,ct <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA. <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL n PVC n OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ;PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FIRE DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS GuIr- perkk a v Lz w�.v <br /> p OTHER: n OTHER APPROX.BORING DEPTH 1 S- tA'Y O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ,A1 CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Alit n lAe!2* Lc • R_�___l_il.r,>,..,1�zr t✓S,w ��,!TI F l? k l"t'� L p 1 <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 Ordinances, Rules an Regulations, and all applicable California State Laws.Signed z J_ Title/Company/7.J`5�-� � �6 -� <br /> Print Name ✓" Date -t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -7C.9:;> tlJcti­ <br /> WORK PLAN DATED: o, {t� 5( III� °I <br /> Application Accepted By— I m+V[ AoV"/' ' Date Issued I ( , Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE ES FEE INFO CODAMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> c0.D1 . �J S`1•`� � lclJ '� 5 l SR# Sq, 88� <br /> C-57_ WCC WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-00 hveb <br /> 6/22/04 <br />