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San Joaquin County 2 <br />Environmental Health Department RECr �' `- <br />SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ►� L"VITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd AUC' <br />SIT IV <br />Well Permit Application fmv�R nipv;J1EN:'� "� <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 />WELL Locatlon36u(IiLIl np,ny{/l 0;, fJ �� aJa1 �1 Cross Street W, tt1ouYVA ty S ZIP q5 Assessors r1 / <br />F � Ci P Parcel# 0 <br />PROPER v{ <br />Owner Address P E, webrer A/'?City S_�_Zip SZOZ Phone# 20q -Y37 - X36& <br />C-57 Contractor U%tyA WC , pnlli��, (C Address SScJ R,, (Zr� City I��o ui Zip y 7/ Lic# 7/007 Phone# 707 -37y -113y0 <br />Consultant / Sub CMr S ,5 C"ndi'Djntti Q, Address aO (4MeM P,4(0 71 Phone# 530-0(0-6,0011 <br />!Mi <br />GIS Coordinates: <br />Y <br />TownshipRange Section <br />WORK TO BE PERFORMED' <br />`WNEW WELL / BORING (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER-) p DESTRUCTION (choose type below) <br />j] SOIL BORING # OVER -BORE. DIAMETER <br />LL# — rrlr vvl w✓�C��lw�� PRESSURE GROUT <br />*Other ,� M 'J GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />`MONITORING OOLLOW STEM DIA. OF BOREHOLE i/ <br />...�_ 0 MULTIPLE CASINGS � MULTI-LEVEL WELL CASING DIA: Z -_ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5, LIy TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUTSEAL Zo' TREMIE TYPE TO BE USED: `AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: p Yes "o (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS j1{'k4 t EYri IeIJ <br />0 OTHER: Ii OTHER APPROX. BORING DEPTH L10' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />COMMENTS: CONDUCTOR CASING PROPOSED AO (if YES, list specifications in comment section) <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 Ord nances, Rules and Regulations, and all applicable California State `Laws. / <br />Signed x �L� G (;i i_Title/Company (, <br />L i 5 1 S <br />C I,! n I I <br />Print <br />DEPARTMENT USE ONLY <br />-15-0 <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED:_ b <br />Application Accepted By "Cp`� <br />Date Issued__p <br />Grout Inspection By L�'� Date q 1 o Final Inspection By <br />Destruction Inspection By Date t <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# I FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATEPERMIT / SERVICE ST # INVOICE <br />35'01.no I3�'o6 �Q gf iY SR# <br />C-57 WC_ -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment oc_ <br />EHD 29-02.001 <br />6/22/04 <br />cl <br />