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San Joaquin County. <br /> Envir"ental Health Department SITE <br /> s M"I ii ��/�'�^� <br /> 304 East Weber Avenue, 3rd Floor, Stockton,'CA 952012 .EI� L'/ AWIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: ww�V.sjgov.org/ehd <br /> ARR 2 6 2006 UNIT IV <br /> Well Permit Application , <br /> NON-REFUNDABLE PERMIT EXPIRES '!YEAR 1=ROE41i DATE ISSUE <br /> VIRONIME #T HEAaH <br /> 4- r~ � � cs <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described,. This app ication is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location&2D3 9:. AW 2-k _Cross Street 1\11A, City SbCkbn Zip 952,15 Parcel#LO I! ' [D 21 <br /> PROPERTY m71 I NG1d <br /> Owner Address Cit 'fD Zip Phone <br /> AddressC-57 Contractor _ . �"Ia}kyr City yYL . Zip U2Q5Lic# LjWPhone# 1-33 (?$$O <br /> L� <br /> I <br /> Consultant/Sub Cntr &rA%V_ Addressj&7 ,thaw. R} City Lic#A80 21a Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: l <br /> U NEW WELL 1 BORING (CPT,GEOPROBE, HY_DROPUNCH,HAND-AUGER,OTHER*) .-AESTRUCTION (choose type below) <br /> []501E BORING# %OVER-BORE. DIAMETER $ _ <br /> rr' <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS f T =/Z <br /> COMMENTS:dghmq IwIs Cvtr- ri ; <br /> b u 6a uv fa ct aS ro14- <br /> kJ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA:OF BOREHOLE. 0 MULTIPLE CASINGS 0 MULTI=LEVEL WELL CASING DiA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 1 <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS.30 <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (:if YES, list specifications in comment section) I <br /> COMMENTS: i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENTOR ENCROACHMENT PERMITS. . <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby cer9fy that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or ances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Companyi5E&-j� <br /> Print Name rS S' Date 2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS' <br /> WORK PLAN DATED: /� d <br /> Application Accepted By Date Issued S 11a �O +� _ Are i 'i <br /> Grout Inspection By r1 Date t Ib o6 Final Inspection By.-m. Lt�, r( Q Date 3Z1 D <br /> Destruction Inspection By Date' <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FETE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 33°1 a3 �o�{ SR# q&,5 j <br />.0-57_ WC -WAIVER C-57 Letter of Authorization to sign.permit Encroachment doc <br /> ERD 29-02-001 <br /> 6122104 <br />