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San Joaquin County Crli <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 SEP 2 4 WTIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehONVIRONMENT UNIT IV <br />Well Permit Application PERMIT/SE HES <br />LIH <br />ES <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 />1 Assessors <br />WELL Location I`i rtt�hli ��y' Cross Street U),!i \/ fit, City Iva ZZip %5 3Parcel# Oio["() <br />PROPERTY ` 1 C, t i <br />Owner IiM<. �2� 1 Address 2737 VV L:n' ftlUbD Ky SC Ci Mc_ Zip���rc PhoUne# «EJ �5' Li pn <br />C-57 Contractor 6f< Address 9'% 6cuic V'A City Ofh- " Zip% 3Lic#c610_ Phone#07-6.313 <br />Consultant/ Sub Cntr Address.3cl�'lt City' ',,O)DL° Lic#6 59LI _; Phone#('110 861-NDo <br />GIS Coordinates: X Y , Township Iy (( Range k Section 3R) <br />WORK TO BE PERFORMED: <br />)KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [] DESTRUCTION (choose type below) <br />FEE INFO <br />'SOIL BORING # .Sf� -IZ� S�'13 Si'j P j [] OVER -BORE. DIAMETER <br />CHECK # <br />0 WELL # ' 0 PRESSURE GROUT <br />DATERVIC QUEST # <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />F5-.-5_Imy <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />4 �- d sR# <br />[] MONITORING ,)HOLLOW STEM DIA. OF BOREHOLE [] 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 />.r <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALg11 tiff j2 J 4k TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br />Q <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: '&Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />••SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ( Wi — LC MQA <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH_81iJ 0 BOLTED TRAFFIC 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 />',) <br />1 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"4 (i'�L'Title/Company�� �c)�S1S1 �K�I��I�'r�C�l�U13C1� �f1C, <br />Print Name t Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By �M�" p t Date Issued ��! Uy Area C <br />Grout Inspection By Li Date 111V6 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: �' Q NJ/ ,marl <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATERVIC QUEST # <br />INVOICE <br />35 0l <br />F5-.-5_Imy <br />4 �- d sR# <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac ment doc_ <br />EHD 29-02-001 <br />6/22/04 <br />