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San Joaquin County UOrp'-, <br />�,UEnvironmental Health Departu D <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ORO <br />� <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.K/�h3 ( [006 <br />IT IV <br />Well Permit Application ENVIRONMENT HEALT <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE gtWITJSERVICES <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 Location Z U4 �// �d LG �1SZd Assessors <br />or o 1 . Cross Street ani City c. v�Zip y Parcel#__� 1 IS - Z <br />Owner �Address Z 3,zc e�®"� ity L _ Zip hone# <br />re 1 <br />C-57 Contractor 3 Address IS -0 �% �oati•i City_J`1s/rinCBip Q YSs3Lic# `IYS Phone# 9 -3 3-6-P'�o <br />fa.f.b�r ..w..�n►•- <br />Consultant/ Sub Cntr_rt��,.d�.dd 2,.c. Address 27Di0elkel s.SI City_%0^0tv%&_Lic# Phone# 74%-935 41,rS-o <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 />WELL # ML/ -.5, M t✓ - 4; a PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS I/ <br />FEE INFO <br />AMOUNT REMITTED <br />MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE 10 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: y <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS YD TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />SR# 004.7 <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL' ' LS TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />C <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes ANo (NOMAXIMUM FrEE-FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS P,rH, la Gcr►�e.�- <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH YS XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED /V (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 Ordinances. Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name_ 1� AC�`�� Date ���� 4_" <br />O <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1"510 C � 7.xa�o S_t <br />WORK PLAN DATED: ILzn(, (7f,- <br />Application <br />foApplication Accepted B l - Date Issued lo l -5, L G Area <br />Grout Inspection By Date 11 1l o �► Final Inspection By 'Date I 2i v L <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT T # <br />INVOICE <br />SR# 004.7 <br />C-57-' WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 <br />6/22/04 <br />