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Can Joaquin County
<br />Envir,,.Amental Health Department SITE
<br />East Weber Avenue, 3rd Floor, Stockton, CA 95202 I ��� '-� ` ,.I�',IA'r ION
<br />68-3449 Fax: (209) 468-3433 Web: www.sjgov.org/eh'd-- CA.
<br />��G __ `' ` UNIT IV
<br />Well Permit Application mg 1 '0 j69'
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />� HEMI H
<br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ;ippHoaxionis�t�tK compliance with San
<br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.
<br />I Assessors
<br />WELL Location 222y q"'4_4'4 �, Cross Street �. gds �� City Sf�c. EL, Zip 115ZO(C Parcel# 1 7�O
<br />PROPERTY
<br />Owner ( Address Z22r[ City Sjo,4o, Zip `l 2'06- Phone# (76'0 y 2 - 2lam Z 1
<br />C-57 Contractor C me L�,I�;rs, Address4S0 City r o:� Zip lYS53 Lic# Phone#/925) 313 -5 -mac,
<br />Consultant / Sub Cntr ddress City_L-±2c{ 4e-,, Lic# C4 Z 7 Phone# (Z6,) q0 - 1 nOC,
<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 />A WELL # S 0 PRESSURE GROUT
<br />0 *Other p GROUT SPECIFICATIONS
<br />COMMENTS: Snn-S,k� (��J r�a� ia��c nc�l�s' �i -_Wew (3C>' (g_n'
<br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS S-
<br />MONITORING S 'HOLLOW STEM DIA. OF BOREHOLE S" a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: 'Z"
<br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SA,. `I0 TYPE OF CASING: 0 STEEL WPVC 0 OTHER:
<br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6 S' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE
<br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED:'XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30')
<br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS I o_� ,1 c ,� z `i- _~}17i
<br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 3e,' Z g o )KBOLTED TRAFFIC BOX or 0 STOVE PIPE
<br />CONDUCTOR CASING PROPOSED nc (if YES, list specifications in comment section)
<br />COMME
<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 �/
<br />Print
<br />Title/Company S -V ff (,ejc,,,� /ti &�
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADDRESS: 2224 Man+7 e)j R oatl
<br />WORK PLAN DATED: re1oruc1,r w 2C 2 0 07
<br />Application Accepted By \/i e-+,,r.:,a. L . NIP ( 11.4.n Date Issued IT - Area /459
<br />Grout Inspection By V: r,+", 4 1t' 64449" _Date 6 1167 Final Inspection By a 7 I/I dt dgS G
<br />Destruction Inspection By fn� /Date
<br />COMMENTS/ CONDITIONS: zrj i��f,`t' �� r)/' ga-t .1c Gi %,
<br />ACCOUNTING ONLY:
<br />AID#
<br />FAC#
<br />PE CODES
<br />FEE INFO
<br />AMOUNT REMITTED
<br />CHECK #
<br />REC'D BY
<br />DATE UEST # INVOICE
<br />351 73,011
<br />84
<br />374. ao
<br />257 /D
<br />SR# 4-o
<br />C-57_ WC _ -WAIVER_ C-57 Letter of Authorization to sign permit croachment doc_
<br />EHD 29-02-001
<br />6/22/04
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