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l <br /> oAa51" San Joaquin County <br /> Environmental Health Department Aou - 2 ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202DATION <br /> �VIR�NtJIENT <br /> �• o. `P'' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/e�', Pi MmsE t NIT IV <br /> Well Permit Application <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 Health Department. <br /> r � Assessors <br /> WELL Location-/I''�2--Dq N S+)Her St. Cross Street ter. G City STOCKG-(DjJ Zipl<204 Parcel# 115-236-04, <br /> PROPERTY ` /' <br /> Owner Cn 17YG1 1 Addres �. �U R2r S�• City Sia CICTL1J Zip SIL Phone#Za'1- y(e 4-3 q5 <br /> s s <br /> C-57 Contractor V ro vi e-A Addresst-3762 Fo(e./ S{.0 7 City VJ&Zp ZipjitS 57Lic# 70SIz-7 Phone#�6o-'s4-7 1o(�s5 <br /> Consultant/Sub CntrR4t,,P-\4 fer�t��CLt�_ t. Address31406e4C6n fill Cityt� 5a«4* t6 ic# Phone# glto-371-047iq <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# ��o-xo P_ �rinS S 0 OVER-BORE. DIAMETER <br /> 0 WELL# J 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 I a-201 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING O HAND AUGER GROUT SPECIFICATIONS CGYY,e-r* { u rr <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH t8-20' 0 BOLTED RAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: be a+ Cf0-,f yx f—ee- - 0,( <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan , s Regulations,and all applicable California State Laws. ` <br /> Signed x �� Title/Company <br /> Print Name ?e-Ael' /" �,1�Q n Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ki 2.0 <br /> COPY <br /> WORK PLAN DATED: / <br /> Application Accepted By Date Issued Area 6 Z� <br /> Grout Inspection By U�4Aftr . Date Final Inspection By L��n c_.� Date O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: V <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z9al �•da 2Z`TSts �s�zs7oG SR# L( <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 />