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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />ORIGINAL <br />RECFJµ <br />Z,E <br />oH <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Wall Pprmit Annlir--atinn <br />JUL v g 200YNIT IV <br />ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 (��� ` f Assessors 105532-0 19 <br />WELL Location �'7�� �� t,G�t►I�t�,►r T _ _. Cross Street QCity "ci i Zip ��Z�IZ Parcel# <br />PROPERTY �Q Th ��! C _, Q/&_, <br />Owner (-"%L- RO(VP,Fi Address ►03't `� &(ec} CityJ�r � Zip iS%I Phone# 3'��O <br />C-57 Contractor p e\(,Y'l;'� <br />ff --Consultant / Sub Cntr W fTr -r.'IL <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING <br />0 SOIL BORING # _ <br />WELL # <br />0 *Other <br />COMMENTS <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <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 ids �crSIZ�CG <br />gMONITORING SHOLLOW STEM DIA. OF BOREHOLE " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _Z��_ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS. ' r -%O TYPE OF CASING: 0 STEEL APVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALS S TREMIE TYPE TO BE USED: 0 AUGERS ];HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: ALYes 0 No NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS T-'�i .1-1a i.et'heof <br />0 OTHER: 0 OTHER APPROX. BORING DEPTHD D" %BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />�},j ' - I_ / <br />CONDUCTOR CASING PROPOSE(if YES, list specifications in comment section) <br />COMMENTS: 1!0q/ A -y- as';1ct r✓154-x1 u.rl 7Y i! f_,q 2_4 e -i- < euAL ik i-- i n onu i�uel I <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 prepared this application and that the work will be done in accordance with San Joaquin <br />County OrdiFances, %1 Rules and Regulations, and all applicable California State Laws. / _ <br />Signed x 1 In Title/Company &g:x 6 V 1,/-p lee A_ �nc . <br />Print Name I l� TT Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: O <br />Application Accepted By Date Issued L 'v[ l Area Na <br />Grout Inspection By Date Final Inspection B We <br />Destruction Inspection By Date 14 <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT UEST # INVOICE <br />�so3 <br />21-9,SR <br />QO��j2Rg <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encr toc_, //4 <br />EHD 29-02-001 <br />6/22/04 <br />