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•an Joaquin Ctranity • FILE COPY <br /> auiq <br /> Environmental Health Department <br /> fit 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 �����ITE <br /> ION <br /> y / (209)468-3449 Fax: (209)468-3433 Web: www.s ov.or /ehd <br /> �:a ..:.:... <br /> �g g UNIT IV <br /> w�u Well Permit Application <br /> AUG -.2 2005 <br /> NON-REFUNDALE <br /> Application is hereby made to San Joaquin County fora permit olcon construct and/or install ES I YEAR FRO FROM <br /> k described. This aTE ISSUED PpENVIRONMENT HEALTH <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /- e /&AVlEEtPliance with San <br /> WELL Location f!Y -/( Cross Street City SAssessors <br /> PROPE TY Q3 30 Parcel# 2 <br /> Zip13-120-02 <br /> OwnerlAddress�-3• W, ,�,_. <br /> ���' City ro Zip rtS;;d Phone# <br /> C-57 Contractor V t W Df"(I. Address p'a 0., At(. <br /> citylsle o„ ZIP t{(Lic#-42040$hone ktv�}} <br /> Consultant/sub Cntr rygo 7--'t iLD v <br /> l't�• Address 2svn dJ•Trwc �°� <br /> — v City rt f-y Lic# Phone# (�at)QgT-t7(n IQ <br /> GIs Coordinates:X y <br /> ,Township Range <br /> WORK TO BE PERFORMED: Section <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 0 SOIL BORING# 0 DESTRUCTION (choose type below) <br /> 0 WELL# 0 OVER-BORE. DIAMETER <br /> 0.Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> K MONITORING OLLOW STEM DIA.OF BOREHOLE r ry�� �{. <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS DAnLTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: t <br /> 0 VAPOR ``77�� TYPE OF CASING: 0 STEEL �VC 0 OTHER: <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 AUGERS -jHOSE <br /> 0 SOIL BORING 0 0 No (NOTE: MAXIM M FREE-FALL DEPTH IS 30') <br /> pHANDAUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH_ Z Z <br /> 0 BOLTED TRAFFIC BOX or TOVE PIPE <br /> CONDUCTOR CASING PROPOSED <br /> COMMENTS: (if YES,list specification in comment section) <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 Or 'nances, les and egulations, and all applicable California SSt�ta``te�, Laws. <br /> Signed x ..4� ,.� Title/Company !i;u <br /> Print ame (.(w. /C AiOTJ- <br /> Date_ <br /> DEPARTMENT USE ONLY Z46S C(/G2 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: f Ll G!�/ � iQ��a n �"rv�n s�PicltG2/ <br /> WORK PLAN DATED: f—II -01 ;; <br /> Application Accepted By Date Issued O �J 'U S 0(� <br /> Grout Inspection By Area <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID* <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �2� 4q ��-38 z sR# pd 3363 <br /> C-57_ WC ✓WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 — <br /> 6/22/04 <br />