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o R, r <br /> San Joaquin r'ounty • FILE COPY <br /> �o <br /> Environmental Health Department oE��;�uI_5:Il, TE <br /> t 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 � <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd TION <br /> .4Uf - 2 20pUNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E[OliRO;JVVIENT�!!`�H`ALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thisapl�tlnOn'rd+li6nIL�F'ompliance with San <br /> Joaquin Countv DA--11-`Title,Chapter 9-1115.3 and the Standards of Joaquin County Environmental Health Department. <br /> WELL Location �J� u�, j� Cross Street City L.�t-� ZI k5'9U Assessors <br /> PROPE TY P P Parcel# (10-0 j <br /> Owner �i.re- I Slh��s Address �'� w• �iF'e }- CityLwF� 4 <br /> """ _ ��� Zip 53:D Phone# <br /> C-57Contractory ` W Address2-0- ??Ox I((. City �Zle}or Zip` s-6.41 Lic#�7.090q Phone#�kle)�g}• q(p0 <br /> Consultant/Sub Cntr reed oy , Ina__Address_2-eto (.f. -fr.��„ CRY 7_1^ Y Lic# <br /> Phone#(20 4)ff <br /> GIS Coordinates:X ,Y ,Township Range 9 Section <br /> WORK TO BE PERFORMED, <br /> A NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') g DESTRUCTION (choose type below) <br /> OIL BORING# <br /> WELL# _ ',,,) DOVER-BORE. DIAMETER <br /> go ther —P�- ----- 'g'—' ""� ^""'"�'� 0 PRESSURE GROUT <br /> —� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> NMONITORING DLLOW STEM DIA.OF BOREHOLE rl tl <br /> 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 1_ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 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 Z <br /> 2 0 BOLTED TRAFFIC BOX orfy,TOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifcations 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 Ordinances, Rule w�and Regulations, and all applicable California State Laws. <br /> Laws. <br /> SigneAmej��" P� w� Title/Company F- <br /> PrintC/T/ � M077 Date 7 OS <br /> DEPARTMENT US ONLY e 2q-6g U/Q_ <br /> �( <br /> SITE MAP IN UNIT IV FILE, ADD R SS:-� R Wim(. <br /> WORK PLAN DATED: —O <br /> Application Accepted By Date Issued V 3 -0 5 Area 06 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERV`IICE R <br /> EQUEST# INVOICE <br /> ZRb g� g 2 sR# p() r3T <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment 74 <br /> CHD29-02-001 <br /> 622/04 <br />