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� FILEC 1 P Y <br /> ' <br /> *an Joaquin County p <br /> r� oy Environmental Health'Department E <br /> N 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 �tl�A► 1 <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd � �1E�LTH <br /> G/p'oft��4 Well Permit Application EPdVIP� I�`�tL' <br /> PE <br /> NON-REFUNDABLE PERMIT 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 /> , p t,r r (� �- Assessors <br /> WELL Location �� �• /Yt s� Cross Street YV I J�. City 6U Zip 95j'#VParceI <br /> PROPERTY _ "� <br /> Owner C41Y 0 I— TP-&cif Address 52U Tra GU �VC�• CityZip�3 Pho�n"e�# 9' y3c1-7 ��2�� <br /> C-57 Contractor G =1 )�_Address2'10(UW/'51&ff. <br /> Address I Dgl E X/iV�' City�CMM_oND Zip 945M Lic#A938'1Phone# O 0-2 <br /> /� �Consultant/SubCntr &&oyMK Irf0WCity-r�1�Lic# Phone#Sb��Dp�J?-41(03 <br /> GIS Coordinates:X= jr� 03Q�:x,Y�t -1(V W( ,Township � J�11 i C1 Range 5 �t�T Section <br /> WORK TO BE PERFORMED: <br /> )QdEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> X)SOIL BORING# �1 d V7af' DyS Ioj SO( ( J90{,-�l 0 OVER-BORE. DIAMETER <br /> 0 WELL# []PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3n 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: --- <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS W TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: []AUGERS [l HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )GOIL BORING HAND AUGER(1-0P3) GROUT SPECIFICATIONSzl.A L AIPa Dy1 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 2U 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED VA (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 State Laws. <br /> / <br /> Signed x A�� ' /i Title/Company ��f Gt t T- l�Y-e l 0,q l <br /> Print Name (_ l�l �Wl OY� Date 7./ 91/0 to <br /> DEPARTMENT USE ONLY cy <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 �" 6 <br /> WORK PLAN DATED: S Z -o <br /> Application Accepted By Date Issu Area 6 <br /> Grout Inspection By Date Final Inspection-By Date Y D <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 22D11:1,oil5l�� !,!� sR# D©�!5 � <br /> WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 a7 •�l�� <br /> 6/22/04 <br />