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San Joaquin County <br /> Environmental Health Department <br /> Tl� � SITE <br /> 600 E.Main Street,Stockton, CA 95202-3029 (01TIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd jWAy UNIT IV <br /> 4<,FO Well Permit Application > . - -` <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EI��(pOr"�E,a( ��1��=i <br /> 'pE M!T/SE,. �Ylcc4 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ma a in�Cbmpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location r S0� /b ,u'y/✓i i U"t' Cross Street �riSNO City S-foe klttJ, i Zip `%S�O�o Assessors <br /> c� -/yd CT I <br /> PROPERTY//// [l [' <br /> Owner_L17� J'� Un-CBP_[/r i✓ Address a�CG IUli✓✓ N%f/lE Cm, ,57 ,� jZip 4`� r Phone# <br /> C-57 Contractor rra A D U / �/ Address 6i /m City �6'O4(14 l ZIpjS,66 Llc#1�/C07 Phonec#�>/5 3G'331-a011 <br /> Consultant/Sub Cntr /' �Pln�e�%t PJ- Address_-C�ItP�� �y'/�t Cih, ;7+-444ic# Phone# 178-1310 <br /> GIS Coordinates:X ,Y ,Township Ran e <br /> 9 Section <br /> WORK TO BE PERFORMED, <br /> KNEWWEL/ - <br /> LBORING PT, EOPRO ,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> SOIL BORING# G <br /> O WELL# 0 OVER-BORE. DIAMETER <br /> — <br /> a*Other D PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLEa=y p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS LVA TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR 0 MUD ROTARY� DEPTH OF GROUT SEAL 96 1 TREMIE TYPE TO BE USED: D AUGERS 0 HOSE(r Iffe) <br /> 0 AIR SPARGE/OZONE XPUSH POINT AGP''or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )(SOIL BORING 0 HAND AUGERL..// GROUT SPECIFICATIONS Tne 1�� /&-/ drPMJ"/ <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH t� D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> (geln CONDUCTOR CASING P/ROPOSED /f Cif YES,list specifications in comment section) <br /> COMMENTS:— , (4 1,Vaos ane CIV-lo dr�,Oc VLK <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 and Regulations, and all applicable California State Laws. <br /> Signed x //(�r.(t.LB Tttle/Company_ (!D jPC7t�PIJ�£rp/5/ <br /> Print Name )r Qip i-s c ,/ <br /> Date ,f//6/0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: x507) /VQ �nr4 S p <br /> WORK PLAN DATED: 51 t-7 JJ <br /> Application Accepted By Date Issued �5/as to Area 3 4 1 ! <br /> Grout Inspection By -Date !0 I' Y-I off- Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> M <br /> NG ONLY: AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE'$ 71130 $3 5�3d7 SR# 5670$ <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />