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a. San Joaquin County <br /> �< Environmental Health Department SITE <br /> r 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202ITIA-I-IOI11 <br /> ' (209)468-3449 Fax: (209) 468-3433 Web:vwc w.sjgov o NOY <br /> a ; 21 AN 9•10811T IV <br /> Well Permit Application S A i .c� r r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUM�iL rY f �`I E, . 'r <br /> L fi Df�iAl <br /> Application is hereby made t4 San Joaquin County for a palrnk TFr <br /> ft 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 Ewnviranmental',Health Department, <br /> WELL LoeatlOn_ . {C) 1 [){t"�IA C a 'i Assessors <br /> _Cross Strut Oc�y D( City CC. P Parcel# 1 L43- ZS` b D <br /> PROPERTY <br /> } <br /> Owner Y�. ZCO?, Tri�S� Address [Stn Z. Tull CMA Cily y`tOC�ti`�io' zip SSD Phone# Z E0(L J- 3 S <br /> �i7'Contractor. E- r�� 1 i� Gs-'7 <br /> "LL+7} C _Address Z 1., f�. ECUS St . city�0.r�riZip 2i L E 2 Phone#0'33DW d�-2_L�2 4 <br /> Con6uttantISub Cntrl-C-M,12L�C,21-k�CChr(c!- A, dress 1LO l -7+A' City i�1c�eS�c �C Phone# 2 52z <br /> � ,,, <br /> GIS Coordinates:X.,Y -- Township Range-3-c—Section 5 Lf <br /> f <br /> MRK TO B9 PE€�F�,.c <br /> XNEW WELL f BORING (CPT,GErOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) Q DESTRUCTION (choose type below) <br /> A MOIL BORING#--- - <br /> p WELL V.. -- p OVE"ORE. DIAMETER <br /> Q=Other .._." �( PRESSURE GROUT <br /> �— LGROUTiSPECIFICATIONS <br /> COMMENTS: <br /> 1 YPE� LMSTALIAMN IXEE CTR CTION 3 CIt EC 1lO 5 <br /> 1l MONITORING <br /> a HOLLOW STEM DIA.OF BORI;HOI_F____,_ Q MULTIPLE CASINGS d MULTI-I.EVltL WELL CASING DIA: <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 11 STEEL aPVC 0pTHER: - <br /> II VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. a AUGERS Q HOSE <br /> Q AIR SPARGE?OZONIw11 <br /> �PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 1`I Yes 11 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ,(SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Irl eat C ry'1Q_i-)+ CV1 tmx+ CQ Tfot.!27 Uel +�Y n 4% <br /> I]OTHER:_________0 OTHER__-- APPROX.BORING DEPTH=" { D BOLTEO TRAFFIC BOX or d STOVI_PIPE <br /> 11 CONDUCTOR CASING PROPOSED � ,,,,�(if YES,list specifications in comment section) <br /> COMMENTS: ki it <br /> . <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT'PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi4,that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Ryles and Regulations,and all applicable California Stats Laws:. <br /> Signed x t <br /> Title►Company_--� <br /> Print Name <br /> Date lC / <br /> DEPARTMENT USE ONLY " a <br /> SIVE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED, <br /> Application Accepted By _Date Issued Z S <br /> Arca <br /> Grout Inspection BY Date 2CD Final Inspection By �° Date a <br /> Destruction Inspection 15Date I <br /> COI4MENTS 1 CONDITIONS: diP <br /> ACCOUNTING ONLY: AID# FAQ <br /> PI~CODES FEE INFO AMOUNT REMITTED CHECK# REG`D BY DATE <br /> 1'i»RI41IT!SERVICE REQUEST# INVOICE <br /> X9.01 C, 7T7lJ,/.(— «fS"as' SR#� �v <br /> C-57 WC.,_,_..,--WAIVER,_, C-57 Letter of Authorization to sign permit-1—Encroachment doc <br /> EFm 29-02-M I <br /> 6/.2/04 <br />