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San Joaquin County <br />9 tY <br />Environmental Health Department 18 2006 <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITI/jy <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT SFRVj �(jy <br />c •.� �P <br />Well Permit Application S <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 />Assessors <br />WELL Location L "i C S W� S� Cross Street W—_rnc;,0h City �rcrk'c'v N Zip Parcel# C.r'l "1 �c L <br />�Lor.ctt <br />PROPERTY <br />ownerc-. Addresslucu\ b��1'�n.a�r city Sc� yin Zip`\452 ,phone#t\ZSi ' 4L -ISA L <br />C.canon �1 �rornen <br />C-57 Contractor C,�.St,�.� �lr'.\\� nWdress 3\� 3 L u <n�c City Z_An Zip'j' •1`f1t-ic# ► S1�hone# r I ) la 38 - U \oei <br />Consultant / Sub Cntr St.c;:,�- S:rtLa: •Address 3u t1 V.kk uw tlACity 0-�Lic#tt-113hone#<`��\,iSC\ot-c4t�� <br />GIs Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />)(NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />,WELL # 0 PRESSURE GROUT <br />0.Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 11 <br />KMONITORING HOLLOW STEM DIA. OF BOREHOLE,_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sci, `fid TYPE OF CASING: 0 STEEL , PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGEI OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: $OTHER So,,,L. APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED ZC) \o ) ° (if YES, list specifications in comment section) <br />�^nvw+roc: n� �1 lYnW • I V- t-- - Lite r-4.3- 3R, mu, mit , �u _ 1 r—, r..4�— _112. , -.a TW -ry ) <br />COMMENTS: <br />�5- l e 'f <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x (Y1` S Title/Company S -" •} � 1-t ."�a c r.a�t ,rry�c� <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z eta 5 Y'yc...\ AOLA <br />WORK PLAN DATED: SI7, (75' <br />Application Accepted By Date Issued?T'� to b Area <br />Grout Inspection By Z.l �MMGw� Date tI,(-Final Inspection By _(fit, �..., .,.c �.� Date 47 <br />O> <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P EQUEST # INVOICE <br />3501 <br />g1.do <br />(o`(Z�A7i <br />Z <br />l� SR#DO X65 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit --Drcreschment dock <br />EHD 29-02-001 <br />6/22/04 <br />