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Apr 28 05 11 : 30a p, 3 <br /> San Joaquin County <br /> DD <br /> Environmental Health Departmen p�``��� t� SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton, CA 9561),�'o� �� kTIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.or� rH <br /> �r • cq� : Via•' 1/r RV/ FACr/PNIT IV <br /> Well Permit Application C <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 wills San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of <br /> San Joaquin County 1Envi�ronmental Health Departmenet. `/�' � '7 <br /> WELL Location 3!5-5-co ✓V GL � Cross Street I`�v City v��/V L Zip s3 9 psseaaoarcel# "�r�kv —03 <br /> PROPER /�/� S <br /> Owner k 13F Address fJ�` R City-joq$G� Zip Phone#T <br /> � , 31,2Cit <br /> Q r a <br /> C-57 Contractor ^ Address City#j _1Ip <br /> Consultant/Sub Cntr__:6 f 1�C /II j Address�4©d VV fi 1 r /t vec CityL Qic# Phone#7f'6— �' �S <br /> GIS Coordinates:X Township _Range section �J✓ <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING PT, EOP 0 E YDROPUNC eAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> OIL BORING# 5� � � OP Jd�' 0 OVER-BORE. DIAMETER <br /> p WELL# a PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: ?tIF ' �✓' f P <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE - !r Q MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA:tY� <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: O STEEL G PVC D OTHER: <br /> VAPOR []MUD ROTARY DEPTH OF GROUT SEAL_D TD TREMIE TYPE TO BE USED: eUGERS jNCSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: Xes d No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS` II <br /> Q OTHER; a OTHER APPROX.BORING DEPTH O FL d BOLTED TRAFFIC BOX or 0 STOVE PIPE} <br /> CONDUCTOR CASING,PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: f�/� 54tl 4�4 ` —1-v <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 prepa Id this application and t th ork will be done in accordwith San a u <br /> County Ordinan es, R and a ulations,a I I i State 'aq <br /> J <br /> Signed I et Titl /Company Clef/ Sr <br /> Print Name y ( C <br /> Dater!✓ <br /> EPARTMENT USE ONLY �f- Z 5?,/mr <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C/ <br /> Application Accepted Bak� Date Issued -S/J r�� Area <br /> Grout Inspection By Dat 2W t� i _Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO <br /> :A:M;OUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> Z9_01 `1- / j��j �5r SR#do`f�-1 <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc <br /> END 29-02-001 ` <br /> 6/22/04 <br />