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N <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />ORIGINAL <br />FO-) <br />L uE <br />QE�VC,o <br />MIT&TION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd JUL !91, 1 200511NIT IV <br />Well Permit Application ENVj,90Nh,iEN I HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/S,C J <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 />` uin County Develonmenr T+iA chi +o 0 111 G 9 --,d the Standards of can i��� „r County Environmental Health Department. <br />1Wit&jn-F <br />�l ��✓✓//��D� -� Assessors D <br />WELL Location l( -y ., , Cross Street , �rLi. &�yCity � t ��L�(�%.1 Zip 'Sz�" Parcel# , /�OIAj <br />PROPERTY //�� <br />Owner S.1ty ._) A:.!6 )',1�Address r �I W Pt4Z�I t�,-\ /tve.City S f ek I(Zip ' 5y Z -� 1 Phone# 2 �1 go <br />C-57 Contractor LtI i fA, Q, Address ci 5+; / orn:T 9D CityA2A/ ?, k, L Zip )V f f 3 Lic# 1`S � y� Phone# r/L f "l %) 5 +� 2'j <br />Consultant/ Sub Cntr R. G . Address_ 3 % S14,9 City✓% ,��( /--.\ Lic# G u ZL 7 Phone# Z j - Y la ;04 <br />GIS Coordinates: X Y <br />Township Range Section <br />CHECK # <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING e C�PT� OPR BE, <br />HY ROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />sl` - <br />0 SOIL BORING # v /f ti r'/ . <br />Ra // 0 OVER -BORE. DIAMETER <br />Z- <br />0 WELL # <br />0 PRESSURE GROUT <br />sR# D 3z -o <br />0 *Other <br />GROUT SPECIFICATIONS <br />' <br />COMMENTS: .S4LA <br />A9" D4T4 o <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE �+ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS N% TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL ) L j ' TREMIE TYPE TO BE USED: 0 AUGERS 4tHOSE <br />0 AIR SPARGE/ OZONE'-APUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes No ()NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER <br />/10 <br />GROUT SPECIFICATIONS T /Av L? Ty�c <br />0 OTHER:_0 OTHER <br />APPROX. BORING DEPTH )L-5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NIA (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 1 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 tate Laws. <br />Signed x Title/Company - r <br />n p <br />Print Name /" ) �_'C Aa Date V 7 <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: 5S _1l 2 -fl <br />Application Accepted By <br />Grout Inspection <br />Destruction Inso <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date <br />)ate Issued 1.125 <br />Inspection By rn'4 Y4 <br />a <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER ST # <br />INVOICE <br />' sg 3(g <br />Z- <br />sc <br />-7.2� <br />sR# D 3z -o <br />7 <br />' <br />C-57 �/ WC'/ -WAIVER_ C-57 Letter of Authorization to sign permit ✓ oc_ <br />EHD 29-02-001 <br />6/22/04 <br />7-1q 0s .y q_al-Zcbs <br />