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ORIGINAL RE( YED SEP u 1 c��• <br />San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9528§CE�'W LIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ch UNIT IV <br />Well Permit Application SEP - 7 2005 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS //�M TN HEALTH <br />- �i�V,JiL <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described .Prtw#flfw nU. a in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Healtli'CSe`0Ah41 <br />WELL LocatlonL�IoQ9 L\) ,S ZD\ Cross Street v �� C'dY Zi 5��� IC Jr `^,j�� Assessors p Parcel# 02- <br />PROPERTY <br />Owner Address U00 S, "lens , City SPK-: S Zipc� Phone# Z L L - � I l g <br />C-57 Contractor S S Address Z L o N City�0��1� Zip ISS 1 b Lic# Phone# S 3 0 .� b �� 2, <br />City O S`)� Lic# Phone# S - '41) 9 1 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />Y NEW WELL / BORING , CPT EOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) p DESTRUCTION (choose type below) <br />g.S01L BORING # i t' S l — C,t ` i o 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 'Other GROUT SPECIFICATIONS <br />COMMENTS `) -1 g' O S �s - S -O -C- <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _____ -- <br />_0 <br />a EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL n PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />n AIR SPARGE/ OZONE <br />Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes <br />0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />n OTHER:_n <br />OTHER <br />APPROX. BORING DEPTH_ <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rales ano,,Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />Title/Company <br />a DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2M L o o m k*S Zo aj <br />WORK PLAN DATED:_,r j� R, 20 0 5_L <br />Application Accepted By V li n Date Issued 9 ' 8 S —Area—/ <br />Grout Inspection By / Date_ // - 3 Final Inspection By//.,� ,,hi�✓f�f�. J �Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: S CPT - 1, ' Z 3 - -S- <br />ACCOUNTING <br />S <br />ACCOUNTING ONLY. <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # INVOICE <br />35'0I <br />C-57 WC --WAIVER C-57 Letter of Authorization to sign permit_ chment doc <br />EHD 29-02-001 <br />6/22/04 <br />