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San Joaquin County <br /> Environmental Health Health Department Fg� 2006 <br /> e; A <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITI aVjFSOY <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd <br /> UNIT IT <br /> `'F R Well Permit Application <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 /> Assessors <br /> WELL Locatlon `�O�a V W--aA- Cross Street City r0(, _Zip Parcel# <br /> JUv:VQhc. <br /> PROPERTY <br /> Owner0c\W%-\� c=mac,,, Address�a0t bv\\'.�f a r City SD w% Zip`\r-15$3Phone#� .2.5) 'rdq ^1S-+l <br /> C.,arr�'�csn <br /> C-57 Contractor Qr.\ ddress •SkP 3 Zamt-r- City2!�Mc Arj Zip!j` 147Lic# 1 5k%one# it torj <br /> Consultant/Sub Cntr 5 ,� s+� .r 'Address_ 3c3 t1 VG-i 1 maw Ojpity Lie# 5 _Phone#(�\,b)y.1-o4t04 <br /> cardivv f. <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> `(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> ,DWELL# Q PRESSURE GROUT <br /> Q`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE,` Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS Sc),, 'Ad TYPE OF CASING: Q STEEL PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> Q AIR SPARGE!OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS pak\cs.\. C­v—`--,tY4A Vx^k-" ZA <br /> Q OTHER: _OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Z Q to 0' (if YES,list specifications in comment section) <br /> -In-, r -+^ 7-(L vr+-M�^ �R, rn�.a..5 A ,'h��--l rn�^")M , -ted TW-N <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 /> Signed x O V`� '(`n`r �5 Title/Company'sa•S•� SCc� S� �-Cssr Lr�ta cy pec\ ,cw.�R <br /> Print Name 'C-SRn\ XMv.4�_ Date 2�15,Ole <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7-10 r,>' cti\00LA <br /> WORK PLAN DATED:_S�� <br /> Application Accepted By Date Issued TU b Area <br /> '� 6 0�_ <br /> Grout Inspection By Z.f'ern.-� Date t o Final Inspection By l4, ����,� Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 S'of 4s1,ov 307i Z ('�' S R# G 15 S� <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 />