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� <br /> San Jonuin County <br /> � COPY <br /> Environmental Health Department [RIECEMqUITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton; CA 95202 �p TIGATION <br /> ( (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd AUG 3 ZCIU�UNIT IV <br /> F' Well Permit Application <br /> <fi n ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <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 9-11111RJ <br /> and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location (45905-Kelso Cross StreetG� Rj City rrcl Zip - Parcel# Z01-03D-o-3 <br /> OwnOe T�wcrlL Co/rwrW,1rt'wr4tcs L4LAddress �12�I TBrad t�+'�cny � Zip 4S_W Phone# 209-936-156D <br /> C-57 Contractor \ ,i T Address Pte- - City Zip Lic# Phone I 100 <br /> Consultant/Sub Cntr LOwYJrLo•r`fNkcll�Address 199 F.e,iL uleS Circk City WALK-ktiLic# Phone# 34-251$ <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> W TEL /BORING (CPT{"GEOP� HY ROPUIJCH,HANG-AUGER,OTHER") .p DESTRUCTION (choose type below). <br /> p SOIL BORING# /[' vi�a� 0 OVER-BORE. DIAMETER <br /> WELL# I /- l- CC D PRESSURE GROUT <br /> 0 Other 5 1//�6/ <�8�0 I GROUT SPECIFICATIONS A <br /> MMENTS: t.JorK dcScr• j- iK�Ac��-�iar.,.� �r« wr.`or c. cta✓ical•Vutl Drmti` ►t'{rrir�orrrr InInrIC Plcut -HPnI Igii' <br /> TYPE OF.WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - rr <br /> `KMONITORING 'HOLLOW STEM DIA.OF BOREHOLE L MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> L EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Sr-pi yD TYPE OF CASING: 0 STEEL ( PVC F OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: C AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ( 1 hE ''V . Ce G 9oI;k <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 12 25 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (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 Ordin/aan/-ces, Rules and Regulations, and all applicable California <br /> CState <br /> (�Laws. /' ' //. <br /> Signed x- !'"//�'"" �II Title/Company -�toti Qolog 4 / C.'Af &A 1". 1� <br /> Print Name nr.i,vl l-rtlt, Date <br /> DEPARTMENT USE ONLY q <br /> SITE MAP IN UNIT IV FILE,ADDR SS: D W lG1c.T/✓ 0"L <br /> WORK PLAN DATED: 7ev� <br /> Application Accepted ByDate Issue _Area <br /> Grout Inspection By Date Final Inspection f Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ?.033 LA7A SR# 4 0 3 <br /> WC WAIVER_ C-57 Letter of Authorization to sign permit--It/ Encroachm <br /> EHD 29-02-001 <br /> 6/22/04 <br />