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`fan Joaquin County <br /> o• •••c <br /> o Environmental Health Department o ITE <br /> V'; { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 IN Crif 0#0 N <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IV <br /> �R{1Fati�� Well Permit Application JUL 1 3TPQQ; <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appIicRi6Rh*"ffWMce with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> IAssessors <br /> WELL Location 43 3 W, 5cyiiS Ti-c Cross Street(4 VICO(i1 sl� City �/Ot& y <br /> Zip q!?W3 Parcel# 7-040-11 <br /> OwnnerERTY ddress I D 9 Swrt)_-A i[A CityPirArnt3t1+ z p432{ q� �2 Phone# S� 4 <br /> 1 - ?0 <br /> C-57 Contractor ddress_710n�C1rttt (City zip /Si72Lic# OPhon too , Na? <br /> Consultant/Sub Cntr_ I/GtM CGGI �fCoq ny Address 937 S � KCl61rA, City, Lic# V�B 2-7 Phone# 9 467-/Oo� <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> LL# t t.J Q-t.0 a PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `'MONITORINGOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:?/1 <br /> a EXTRACTION ,'`AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING: a STEEL PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL/-')- I TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Ha llej 64414A.1-j- <br /> 0 <br /> 4414 '1-j—a OTHER: a OTHER APPROX.BORING DEPTH—r_�z::;j KBOLTED TRAFFIC BOX or a 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 Ordinances, Rules and Regulations,and all applicable California State Laws. tt <br /> Signed x iJ <br /> t _,, i- Title/Company ^t?.D I (S t- 1 i/Ja( 'U2Qt 4rP11CCY( <br /> Print Name 01 V-) 1 P I�l t���yVl t P V\ Date Z/ 05- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: y 33 _.sCo415 <br /> WORK PLAN DATED:���Q5 <br /> Application Accepted By Date Issued7��S�O Ar <br /> Grout Inspection By Date / Final Inspection By 1 Date 0 <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/SERVICE REQUEST# INVOICE <br /> 3Sa ? 3� <br /> =65 <br /> SR# <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 />