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w t <br /> an Joaquin County <br /> Environmental Health Department Sff S ' E_- <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <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 Deve <br /> lopment Title,Chapter 9-jj111�1..115.3and <br /> ''''the Standards of San Joaquin County E-n�7viironmental Health Department. 1 �1 <br /> WELL Location 32 `� �I(lC{� Cross Street V Ul°� City�f� ZipgS Parcel#Assessors <br /> 1-74 <br /> PROPERj. <br /> Owner LtJU�/ ,�1N I I�l�tlg, Address(Sn 1t �NaV _ yCitY ZipQ Phonne# �p�n/� � /� <br /> C-57 Contractor �` (� 111 Address 32 e[ C�f�(`L�e cit y,1 jI� Zip J 4ic# I j2 Phone* l 110 t �P t-I((V 1 <br /> Consultant/Sub Cntr�U1 ( C (A Address V5% MCt(p1'1'IVIt�' l)utiityc.UA AAKALic# Phone# <br /> h.r r <br /> GIS Coordinates:X-�fVol loil _,Y I� �2/lsV Vownship ( 1U Range Section <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ' ESTRUCTION (choose t efb7low) <br /> a SOIL BORING# ER-BORE. DIAMETER //_ <br /> ®WELL# PRESSURE GROUT <br /> ®*Other GROUT SPECIFICATIONS <br /> COMMENTS: {_��JAJOA <br /> CJf�Uv!U <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP CI (CATIONS <br /> ®MONITORING ®HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS ®MULTI-LEVEL WELL CASING DIA: _ <br /> Q EXTRACTION ®AIR HAMMER/DRIVEN CASING THICKNESSqD_TYPE OF CASING: ®STEEL ,OVC u OTHER: <br /> ®VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: o AUGERS ®HOSE <br /> ®AIR SPARGE/OZONE ®PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ®Yes ®No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING ®HAND AUGER GROUT SPECIFICATIONS <br /> ®OTHER: ®OTHER APPROX.BORING DEPTH ®BOLTED TRAFFIC BOX or a 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinancrIlles and R ations,and all applicable California tattel/JLaws.�I 6r&,i4wa,,9 <br /> Signed x Title/Company �'"' 1. � �` ha <br /> Print Name � (/� led Aa NaO Date � l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /s <br /> Application Accepted By / ! P IoG�7t a i Lu g W Date Issued —Area � f <br /> Grout Inspection By Date Final Inspection By 44��4_�� to �!"7 S d <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 /> 40y. -7z 4-0 a a_0 -2377 Yf 7 Q6 sR#n� a 0 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 FA. 060 V7 C <br />