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-- <br />San Joaquin County nS (���%J C <br />Environmental Health DepartmentSITE <br />_ <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 JAN 7 ?OOKAITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.or RONMENT HEAD UNIT IV <br />Well Permit Application PERMIT/SERVICES <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />a4" i3.. <br />y m4Qs14 sr. c:,,-::,<^ c�..�., i Assessors <br />WELL Location 4v -4LA 7 'b -I -c k ka Cross Street Ai ✓' City 5 4r k tDo i Zip Parcel#O - 0) - CC j <br />PROPERTY <br />Owner j!E-t� r 13, , 64 (4% Address ! gC)" w' "1,:; , h y >~ City 5 ia�.�fti�� Zip %'S �i'/ Phone# ZC'ri -'"t"-RC)CIt) <br />C-57 Contractor •/I///+- Address — City Zip — Lic# - Phone# <br />_ .1 C' . C L.," <br />Consultant/ Sub Cntr_Address 3 7 K,lc, a'2 City_ 4..1o. Lic# Phone# `/« -y61-C"10P <br />GIS Coordinates <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING <br />SOIL BORING # <br />0 WELL # <br />0 'Other <br />COMMENTS: <br />Towns <br />(CPT, GEOPROBE, HYDROPUN H, HAND-AUG_FA, OTHER*) <br />lL 2A -C-, 3i4 -t_` <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 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 /✓/4 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />R SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />701E BORING AND AUGER GROUT SPECIFICATIONS i✓f� <br />0 OTHER: (0"OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: � , • A 1017 i"WiS � xfj .. -)k. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PFRMIT.q <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 />Signed x \� - — Title/Company Sri 0 5+ <br />Print Name ycLvkto"- y ; t Date 1/310 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: t�/� <br />WORK PLAN DATED: <br />Application Accepted By j - Date Issued (� I D Area <br />Grout Inspection By 14k." Date S C, Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS: Lor <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />- CODES <br />3SOr <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # INVOICE <br />r i p SR#5)Fob `/-o B8 <br />(711- <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 />r <br />O <br />