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l <br /> Ul1'�..�o '-8an Joaquin County n <br /> Environmental Health Department W�(�;[gmjcrp) <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ITIGATION <br /> CC (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd iuM U4m <br /> � �P <br /> Well Permit Application ENV/ <br /> PERMIT H <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /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 /> Assessors <br /> WELL Location 24 S• L,-nc�l n S1 r e,�-I• Cross Street 'VV. SCA+S City��Ot��01� Zip q 2U3 Parcel#_147—OQ7 <br /> PROPER -gyp (� p <br /> Owner !'d n k S IJ yeriO Address,'9Z4sunb 1 B I�VC1, City f 6ASUiY 6r)Zipnl�Phone# Z� 2 0L I <br /> C-57 Contractor Iqw�ti �cz, �t+1N. Address 53-7.SV1Gy.1 IN City�TC 6 Zif U I; Lic#(46WPhone# —/d0� <br /> Consultant/Sub Cntr4&/& (1��7Tt,Ueh V. Address 7 Sk&W City_SlftkW Lic#k Z Phone# 2 10— <br /> GIS Coordinates:X T Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,IEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# I 0 OVER-BORE. DIAMETER <br /> 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 2 0 MULTIPLE CASINGS <br /> 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 SE���AL��_rtt�-rife TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ffl-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS�+Lk�r (u vtcl C. 'A'eA+ <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH_L_7:?,S 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED&_(if YES,list specifications 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed r Title/Company t-'; 1t1Y1 OLVkCAd EnU <br /> Print Name_ Q Y� 1{ 1 fl, Yk 0A r Date 1 1 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DR SS' x-33 <br /> WORK PLAN DATED: O <br /> Application Accepted By Date Issued Its/-6S <br /> Area <br /> Grout Inspection By L Date inal Inspection By Date ';L40 O <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 /> $ 3(off oZ�`l Gj (� =1:5 S R# Lj3 0-7 <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 />