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San Joaquin County <br /> t Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 952(2 0541TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sj28Qf cT PI`� I <br /> UNIT IV <br /> Well Permit Application segceuNT'r <br /> [4VIR0IjKENT'11L <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE-!§4�€I>SH DEP,�RTMENT <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 /> rr / Assessors <br /> WELL Location q,4z1/V. Suffer f�. Cross Street At" �• City S7'OCKIOAJ Zip ol$2o Parcel# -2'30- 04 <br /> PROPERTY/1 / ,'/ p 11 -/ q '/ <br /> Owner ,0//Or. / AddressyZOrl J077//�/ City;!L`'G 17r ZipgS2��Phone#20/-YG7 - 3��!✓/,t` <br /> C-57 Contractor V/loA�Je X Address2376l f'O ! 11-4City! �" ZOYSV$ Lic#70S9Z7Phone#I k608Mo <br /> oO TJ <br /> Consultant/Sub Cntr11A11e rxAeeI'l r&j.f*Address V. city($-Sano ic# Phone#9/(, 371 D y W <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 5 go fill-Gs Lj-r- 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 /> []MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> [J VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 3d TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> []AIR SPARGE/OZONE -gPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS C<WLCKk 4-Jff <br /> []OTHER: 0 OTHER APPROX.BORING DEPTH SOS - Cf 6` 0 BOL ED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: CP. M��_ =n / r u f <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby <br /> County certify t t I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Ordin a egulations, and all applicable California State Laws. -/ <br /> Signed Title/Company <br /> AG� �/ d/ �� ¢ l`GK rLt/ C• <br /> Print N me Pe Y. a 7 a/'� Date Z9 8 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: g2,0Lf fV• <br /> WORK PLAN DATED: L'Z 4S06 II <br /> Application Accepted By tom-- Date Issued 3��1L/4�o Area <br /> Grout Inspection By Date jj z O 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# REC'D BY DATE PERMIT/SER/VICE REQUEST# INVOICE <br /> 2,101 #6'C('oo zZ-obl h-t 3/7 r� SR# q l 1 g Z1 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EI-ID 29-02-001 <br /> (,,22/04 <br />