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pAYM�N� ORIGINAL <br />>a' San Joaquin County REGE�v� <br />z `\1 Environmental Health Department �Ay 0 4 �� SITE <br />N: 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 Cc�ITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd N �OPOU�MENTP e <br />NV\v"ko1 RiMF UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OF CS <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 complianc with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL <br />p <br />WELL Locatio� �225Z�—fZ;, , J,.k ), Cross Street C "Ay -c -c-+ city OY1 Zip 'q�ZgParcel# /�Uuj <br />PROPERTY �+ <br />Owner;' Address 2.2lEk A Oektr iYUf 33 ffCity� tby\ Zipc54DZ Phone# 1-541) <br />3b�2 0 <br />C•57Contractor 11IcLe Q (� O�lllAddress W1eGlcV Ci�jYaUc�rr C f�f5 ic#1]�QPhone#ij6 <br />Consultant / Sub►�tYi JV1 L1n111i'b\tYLlC 4( 71/�ddress 0 YV\vm'ti #�CityGi DoPdic�p_ '5 Phone# b(6 93� Z(70 <br />GIS Coordinates: X -'Y Township TI Range RG L Section S zJl <br />WORK TO BE PERFORMED: <br />j NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) tom. <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL # 0 PRESSURE GROUT C <br />0 `Other GROUT SPECIFICATIONS <br />COMMENTS: ov t i TD •a 4-67 A " 14511 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING I HOLLOW STEM DIA. OF BOREHOLE V 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2z.," r <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS '�r-VaJ 40TYPE OF CASING: 0 STEEL @ PVC 0 OTHER: ` <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL:3:j-7t&d TREMIE TYPE TO BE USED: $AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes III No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS r -CL} C(Wvi----�Ni <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH X00 a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED I jo (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 h ve prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinanc s, RI s and Regulations, and all applicable California State Laws. J <br />Signed x / L _L' -T7 L ~ Title/Company l (G C lI.���tlCs��Y. f�� 11 Ci t li� /i�1I wi�wk 4 It,t <br />-- <br />Print Name /Ify4/ 7661eV,( 4.L'�'. iV; 5 & l Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z 2-,? 57 Fi <br />WORK PLAN DATED: <br />Application Accepted By Date Issued 6 Area AO 0 <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Dat_ <br />COMMENTS ! CONDITIONS <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />o/ <br />S R# Cvl� 3 <br />C-57 ✓ WC 4' -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc_ <br />EHD 29-02-001 Q <br />6/22/03 : 1641 • % <br />