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"�E"rc' P I A I N A I <br />San Joaquin County 1!A��1 5 M, <br />Environmental Health DepartmentE.�UUlRONEV� N l. ? :;',.__ ;$ITE <br />600 E. Main Street, Stockton, CA 95202-3029 p�QftpIT/�ut?�/I�TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application � �y�/ q d � <br />NON-REFUNDABLE PERP. M. IT 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 />CcW n t•f - CI v6 '61 � Assessors <br />WELL Location ��51 Co.,n f,� CIvN �ivt�CrossStreetE �= ) City S10�,KTon Zip 9S2a�/ Parcel# <br />v E. <br />PROPERTY/� CI vJ� <br />Owner JaH,.) PAAitAddress zl�nlr-j 40viocity S'TokKCb'AZip 52oYPhone ? 4(b `Z7/S <br />C-57 Contractor A..G L Address "53 7 S)4/4 ­ J RA City S To L.Kr�'Zip9S'Zlr Lic#6S'jzz7 Phone Z"I Y6 b <br />Consultant/ Sub Cntr x/14 � . � Address�S3 7 S4.4 v✓ Ad. City StcCICT . Lic# LaZ2 7 Phone#(" `;'r) 4 Z' <br />GIS Coordinates: X 3 T- `o4th Y ZI • 3X e Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING (CPT, GEOPRO EBE IYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />SOIL BORING # P'/ 7 <I -Z0 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other _ GROUT SPECIFICATIONS <br />COMMENTS: <br />=2AW!j"J:1B <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: ti/A <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S' TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />0 AIR SPARGE/ OZONE AIPUSH POINT GP or CPT)GROUT SEAL PUMPED: 0 Yens _4No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Tat` T [AN,O T4PL IL <br />0 OTHER: 0 OTHER APPROX, BORING DEPTH S' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />COMM <br />CONDUCTOR CASING PROPOSED IVIA (if YES, list specifications in comment section) <br />SAF kWp-/�o�R�.I�I L4ykr . cl Tkn c_�;?JI'OQ7 <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 Californian State Laws. <br />Signed x 4 C, <br />—� � Title/Company %�+ " c GOO 1 <br />/ ? <br />Print Name /,, *n c TN 1 C1/ E 4P Date 01&5- ` <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By. <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />C <br />G <br />D <br />ilS�9� 7� NO <br />c</ COc� uU�!6P <br />Date <br />FOI <br />)ate Issued Area 46 <br />Inspection By e <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODE <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE EQ # <br />INVOICE <br />� S <br />`� <br />3i�.`� <br />1 b <br />�. <br />l'2S• SR D53SG <br />C- WC -WAIVER_ C-57 Letter of Authorization to sign permitE�lcl=oachme_�T-1�`� <br />EHD 29-02-001web ` <br />6/22/04 <br />