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San Joaquin Count ' <br /> Environmental Health Department SITE <br /> { 304 East Weber Avenue, 3rd Floor, Stock on, CA 9520 <br /> joOCT 31 pW91.aATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: wvw.sjgov.org "T IV <br /> Well Permit Applicati n Safe �`' '�`�''" Coy <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDHE A LTH DLP t.R T HENT <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 C unty Environmental Health Department. <br /> _ ` Assessors <br /> WELLLocation ��7 oSeMi�2 ,Sf. _ Cross Street L`�c� t. City S c< {ate Zip cl'52CS Parcel# r35-ZC�c�`�y <br /> PROPERTYF� ,((�� I f► // ii <br /> Owner I P,r.2/ VyL Dr,,-d Address 34 '/-:ee tik S4f: City � o^ Zip j5Zc3 Phone# 20ti&G- ZZ00 <br /> C-57 Contractor Dr:l);a,,.l,nc..Address 3GS2 6ruef- rir it C"'-Zip qSj Lic# 75IQ Phone# (4I&)(a SR 1Y, <br /> Consultant ISub Cntr :H�vaw[-•� ?°c2.aV. Address City +oek' ,L Lic#��[ —r Phone# (16'1 t�7-foot^. <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL l BORING (CPT,GEOPROBE,HYDROBUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) JJ <br /> o SOIL BORING# d OVER-BORE. DIAMETER <br /> TELL# NVJ- "1i S., q / rc 0 PRESSURE GROUT <br /> a"Other IGROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING W-IOLLOW STEM DIA.OF BOREHOLE $` "a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS c c: k TYPE 01=CASING: 0 STEEL (]PVC 0 OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ^ + TREMIE TYPE TO BE USED: p AUGERS D.HOSE <br /> Q AIR SPARGEI OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes gl o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING o HAND AUGER GROUT SPECIFICATIONS__&0. Le, <br /> a OTHER: p OTHER APPROX.BORING DEPTH 10, <br /> g'I!3OLTED TRAFFIC BOX or a STOVE IPE <br /> CONDUCTOR CASING PROPO ED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIR ED 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 Stater Laws. <br /> Signed x Title/Compa y Sfaf <br /> Print me o`t< � a1� Date k O — 2(,- <br /> DERARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> f <br /> Application Accepted By .�{.,l Da a Issued Area /'7 <br /> Grout Inspection By Date Final Inspection By Date 100 <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> L FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# tNV010E <br /> %- 3{aS°—° X3057th etc_ !r eSJ SR#p'0y14'3('�' <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to ign permit_Encroachment doc_ <br /> 131+1329-02-001 <br /> 6/22/04 <br />