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ul San Joaquin County i <br /> r � Environmental Health Department <br /> { 600 E. Main Street, Stockton, CA 95202-3029ITION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chd AUG <br /> IT IV <br /> Well Permit Application <br /> ENVlRO€�r"� �AiT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMITISERVICES <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location j Z 00 /V. 4,e kW u�l Oil f Gross Street Fop 0 t c 0 p City_5`f'oc k f ors Zip 1 5 Z I Z Parcel# DESS" -7/0- <br /> PROPERTY a�Z� 1 1 <br /> Owner ?-*I 5cADtA+4V/F+wrkP Address 301 $- A V1-0+o1 Sf•, City STdGkTuh Zip 4L97o Phone# -7 "'if b(o -0'133 <br /> C-57 Contractor V*W Address PO go-A „a70 City LoAL Zipg5Zy Lic# j� Phone# 369-9600 <br /> consultant ISub Cntr (rteu-cl 2e'u Ar417Sr)AddressI71At Mpir+ City !r c o., Llc# Phone# e38-7$$k <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> SOIL BORING# C-5 1 +Cg-y 0 OVER-BORE. DIAMETER <br /> ,WELL#AA%J 1`1 !K W 19 C_ Mme'IRP 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF.WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING IkHOLLOW STEM DIA,OF BOREHOLE!41Ip MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:-1 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCA+• q 0 TYPE OF CASING: 0 STEEL $PVC 0 OTHER: <br /> 0 VAPOR XMUD ROTARY DEPTH OF GROUT SEAL B0`— Zg2 TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br /> 0 AIR SPARGE/O ONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: gYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ne«+ ee�--j <br /> 0 OTHER:^ Il OTHER APPROX.BORING DEPTH`6nf13&1361 .300a BOLTED TRAFFIC BOX or 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 vOrdinances, Rules and Regulations, and all applicable California State Laws. L 1 <br /> Signed x �" 06 Title/CompanyS�`� yenldrliST/ t-"O'd ►CI. ZC'-D Ayp�ys�s <br /> Print Name 0 V a IA Date <br /> —� <br /> DEPARTMENT USE ONLY FILE <br /> � <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 9Z_OO 0 . � cI S <br /> PY <br /> WORK PLAN DATED: <br /> Application Accepted Byof Date Issued S' e. b Area <br /> Grout Inspection By [JL�L,¢,_ Date Final Inspection ByDate 2 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3So I .oa Ot}I 5- +,3 SR# S l 5 33 <br /> 3s"b Z'ifs ode � <br /> I <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web i <br /> 6/22104 <br />