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URIH Oban Joaquin County <br /> Environmental Health Departft , S �°� kW' ITE <br /> " 304 East Weber Avenue,3rd Floor,Stockton,CA 95, O '9� GATION <br /> P' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org� (��� ��7 UNIT IV <br /> g4FORt' Well Permit Application FRG�C,cq�lh' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 H alth Department. <br /> WELLLocationYy I u• W as I 1u 2ross Street JP neCity S ati _Asse1 �V 4 <br /> UQParcel# <br /> PROPERTYAM(-tl(,4✓ Yh0-I0�^y <br /> Owner cl• k1 fllu.✓h CumP Address 9-M LAK City ip9S 8 P o� -i-+ll I <br /> ' µoo� s S 8� <br /> C-57 ContractorP f C C(,{,u in C Address' � t"� `� - • �ity Qwhnwn4zi ti hone#�(V d-3}1- Lt S}f <br /> Consultant/Sub Cntr_/t'1+C_P r-C Address;31f 1 (114 Acjw J 1/u(�fity)I`L � Li Phone#?o� ..-If 3-: g ai <br /> (.� k '1 JaITr Ou <br /> GIS Coordinates.k -r��- I •1 ,Yah 3�. q Ud- ,Township Range t Section�� <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (GPT,GEOPROPE,HYDROPUNC)-I,HAND-AUGER,OTHER') 0 DEST UCTION (choose type below) <br /> ((SOIL BORING# aLL I }� ,'}J I h �+- tU t k /v ^l 0 OVER- ORE. DIAMETER <br /> 0 WELL# 0 PRESE URE GROUT <br /> 19 Other r u ac a a. �•+ '^� I s y r n GROUT SPECIFICATIONS <br /> COMMENTS:_Qa,A C1 JQ.0 S Icj h 4 O <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGSMULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASINI 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE PE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE)OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> WOTHER:_uu l GO IZOTHER fr k )) APPROX.BORING DEPTH l�� L{V 7 0 BO TED TRAFFIC BOX or 0 STOVE PIPE <br /> U - J CONDUCTOR CASING PROPOSED No f 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 lations,and all applicable California State Laws' <br /> Signed x ---,a D <br /> q"� Title/Company Q. v/- GQ U c <br /> / <br /> Print Name ( rQ 1-44 /-F- da.iM,.n Datf el <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Byl ,e Date Issued /�� 1 / .L )� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PE IT/,`SERVICE R7EQUEST# INVOICE <br /> ltj <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorlfzoti o sign permit_E icroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />