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ORIGINAL <br />San Joaquin County RECE#W/,-- <br />Environmental Health Department - IITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 I f-fGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehdJUL 2 12005 UNIT IV <br />ENVIRON 1 <br />Well Permit Application N.ENT <br />TH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 />(..')ky Uv$ &V0 Assessors 2^ <br />WELL Location 'Zi O-5 C..,itty CwyA 81y�Cross Street City 5T%l� ('..J Zip `15Yd Parcel# Z� <br />tJb.?4f <br />PROPERTY y _ <br />Owner MAA K SDri I�C'�S�-Address `L��.3 QVA hl k"b City S %r1C 1R �' .� Zip`IS 1� Phone# <br />C-57 Contractor Gr& ' �,l�I 1t. Address 951Q 44WF– ff b . City T: L Zips yS53 Lic#GS�YO'khone# j 45413 ^S1f'Z110 <br />Consultant / Sub Cntr A r Address 937.5,q.4w 1t0• City5/oC<T(-j Lic# ULL Phone# 1•516 <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL /BORINGCPT <br />G OPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />ASOIL BORIN# - 1 0 OVER -BORE. DIAMETER <br />r 0 WELL # 0 PRESSURE GROUT <br />0 *Other �1 QjA /� GROUT SPECIFICATIONS <br />COMMENTS: s�� RPPA --w0 Vg o #Q K /"/ri 097. 0 iIt M4 -1 'z -` ; 'i W <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 7-,i 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -M TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NIS+ <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED: 0 AUGERS .HOSE <br />0 AIR SPARGE/ OZONE-ZPUSH POINT (GP or r itGROUT SEAL PUMPED: AYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS PPP T t'ArvD <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH I Z5 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, Rules and Regulations, and all applicable California ate Laws. <br />Signed x /--� �~ Title/Company <br />Print Name F / ' % �% . Date R <br />DEPARTM_�E-�N, �TT� USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date Issued —Area O <br />'•' ''J <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />C-57 WC / -WAIVER_ C-57 Letter of Authorization to sign permit�hTRentdoc_ <br />EHD 29-02-001 <br />6/22/04 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />3�>-J <br />uLt-vf <br />SR#op 732p <br />C-57 WC / -WAIVER_ C-57 Letter of Authorization to sign permit�hTRentdoc_ <br />EHD 29-02-001 <br />6/22/04 <br />