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`van Joaquin County <br /> Environmental Health Department ( E� �� <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 IVIIC�X�'IrifllV <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd JUL I T IV <br /> Well Permit Application PP ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Standards of San Joaquin County Environmental Health Department. <br /> F' /{ 1 t� Assessorsy I <br /> WELL Location X33 W S CO 4,5 AV& Cross Street L;nLV1 Yl 5: City S rDt. 4*N Zip �Zo Parcel# –/�77-D'9D <br /> PROPERTY <br /> OwnerwoCo�1��tt4:1. t ► t/YHddress IDSWs �anS n - Cityp;tr)M(214�Zp Phone# 1St/ l___.L3.0T /^ <br /> C-57 Contractor��{ ^/� 11 ri 1' Address 950 HtWe K�GY IICity Y �2Zip94S Lic#45W/,one# S 3l -->600 <br /> Consultant/Sub Cntr/}/)V&k ��►1,1/ Address g�7- htw) M CitySbclt�t�Lic# UZ 7 Phone#00'7)4 67-100f- <br /> GIS Coordinates:X —'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING CPT,GEOPROBE, HYDRO PUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# C PT 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <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 HAMMER/DRIVEN CASING THICKNESS�TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �-Vl h)re TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes OUNo (N/OTE: MAXIMUM FREE--.FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 11D fTI�M/l! Ghultit��y'4 <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH r /on r 0 BOLT'D TRAFFIC BOX or 0 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 /> 1 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. <br /> Signed ` Title/Company LE–y�—"�ISt !'Gt VakoXir U <br /> Print Name 1 of Y) ► P P L-N Date 7/ 10-5 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES <br /> WORK PLAN DATED: ILI I, <br /> Application Accepted By Date Issued r S/V Area <br /> Grout Inspection By c Date Final Inspection By_lr, .L f– O Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY FDATE PERMIT/SERVICE REQUEST# INVOICE <br /> 5� 5 $ 3�� �q� 7 /S�s SR# 30� <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 />