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San Joaquin County <br />Envi_ ,nmental Health Departm SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA_� h -*ME MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application JINN 0 12007 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATA I3SLtFWJIEiU i fiEhLTFI <br />�s,tt,,IIrr <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work descri etf.'I i� Nd9tF075 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 />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or nce Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company '\Jice IWesiclenl 1 I1duancnd Genelmi,vnnayala I <br />Print Name F\nrle.t Date of JUn�4 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 3 1 1 7 10 -4 -- <br />Application Accepted By Date Issued Area <br />Grout Inspection ByDate 1 Final Inspection By //lrkhnns� Date <br />Destruction Inspection By Date' <br />COMMENTS I CONDITION <br />ACCOUNTING ONLY: <br />Assessors <br />WELL Location i2' <br />`.' R,r F lr, .; Cross Street c.,6t=;jk City NU'v—iL VVI Zip I' ? Parcel# j39-lu'2,-0I <br />PROPERTY <br />CHECK # <br />Owner k'_r,\(4 Lee <br />i 2y)iAe Address '1203 S N,,ptw�City Zip %,Ob Phone# 209-44(jLI•531I <br />C-57 Contractor lili k ?ti <br />J�hanLlonmrrjF Address 51509 -PI (0<'oot UUtIFr., PJ City Plc4ceruilie Zip qZ(I Lic# Phone# 536-(jyCl -Ii 22 <br />Consultant/ Sub Cntr (lctyancecl <br />[Address 33-1 Snow 20 City g;nckAZO Lic# U<j + 1 Phone# 2Dq- 4ul- Ibclf <br />GIS Coordinates: X <br />Y Township Range Section <br />Q <br />WORK TO BE PERFORMED: <br />;NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) t <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />it WELL# hi'(' <br />4, 1, -kW IW -(1 0 PRESSURE GROUT tl <br />0 *Other <br />GROUT SPECIFICATIONS Y✓ <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING <br />HOLLOW STEM DIA. OF BOREHOLE',, L� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL $PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY DEPTH OF GROUT SEALS (r " TREMIE TYPE TO BE USED: SAUGERS SHOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER GROUT SPECIFICATIONS 1-111 NeCIA O'eme n l <br />0 OTHER:_0 <br />OTHER APPROX. BORING DEPTH 36 hso. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Or nce Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company '\Jice IWesiclenl 1 I1duancnd Genelmi,vnnayala I <br />Print Name F\nrle.t Date of JUn�4 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 3 1 1 7 10 -4 -- <br />Application Accepted By Date Issued Area <br />Grout Inspection ByDate 1 Final Inspection By //lrkhnns� Date <br />Destruction Inspection By Date' <br />COMMENTS I CONDITION <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PE EST # <br />INVOICE <br />3T35 <br />­C <br />�-$S oa <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 />