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Pq�'N San Joaquin County <br /> Y � a Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 952PAEQ@W <br /> IGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> OCT 206 <br /> Well Permit Application Z� - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE lSS1IM"ARONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described.paWTI 4E GE&in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> "� Assessors 7L <br /> WELL Location 0 Lt �' �urnu 9 ' Cross Street S' I�#vYl City L-0CtI Zip�`P Parcel# �l N_ ` <br /> PROPERTY * MIS p1 tUl�vlwk ?RX `SteD t �'(/ �� I�L xj / _CRL1�_ (p Sb <br /> Owner _�Gl r��n Address c� City_��17c +01TI Zi p Phone# G� �y { <br /> C-57 Contractor ''�,N�--) Address I j►Uf�''` �L`Cityy �,ki M411�tl(�kZipL JLic# �JrI1 Phone# Ili �� — a <br /> Consultant/Sub Cntr wVJn� ✓�i !)Dqt A�Jdress J0)Crypt ST • skocity. 4 ic# Phone#1510 245 c7a) <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: lvin,: S{e4-y1 -:1(- <br /> '*NEW WELL/ BORING (cfj, EOPROB HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> IL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0*Other I GROUT SPECIFICATIONS <br /> COMMENTS: otAt ct aF bm S- c; rol- �eec i Sam �S W%Ik 6e Sworn'tkd, fZt fy,it� <br /> /- U P AD <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLEv tt 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 TREMIE TYPE TO BE USED: 0 AUGERS gHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE• AXIMUM FR E-FALL DEPTH IS 30') <br /> SSOIL BORING �0 HAND AUGER GROUT SPECIFICATIONS <br /> /a OTHER: 0OTHERAPfJ� APPROX.BORING DEPTH 5 D 0 BOLTED TRAFFI BOX or 0 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> (� ((1 I n <br /> Signed x ,, •,,,^ n Title/Company S i�tt"f O" ' �(j(4)ft' 43MA awptA <br /> Print Name � In b' �/ Date] I Ll4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL , ADDRESS: lb� <br /> WORK PLAN DATED: to <br /> i <br /> Application Accepted By Date Issued lobvDIZ, Area V7 <br /> Grout Inspection By Date G I 6 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: O WZA, C U WCZC-_L} <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Lal�j SR# C)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 <br />