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San Joa uinCou,_n c CR <br /> � <br /> QPy <br /> D C' <br /> z'' o Environmental Health Department NOV _ ITE <br /> a: a - <br /> X 304 East Weber Avenue,3rd Floor, Stock on,CA 95202 IITrcATION <br /> I <br /> (209)468-3449 Fax: (209)468-3433 Web: .sjgov.org/ehdE�jvlROjENT H IN <br /> �gtpF:o ta�P. PERMIT/SFRVI( <br /> Well Permit Application <br /> J/�� <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED �! v /rL WI V t/- <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install th a work described. This application is made in compliance with San <br /> Joaquin Co`unty Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Loc atlon 1� CAGIF�N/A ST Cross Street �'660-r4IV -zipqr Assessors <br /> ("l/(/� City �Parcel#/2S-3S'— I�p <br /> PROPERT-Y <br /> Owner HM6/V /f/44/A4 Address -?/S Hd244d AWX Zip 7SZ/?Phone# 24� Qs/ S7/-V(0 <br /> C-57 Contractor San" t'41 G&d.2, Address ,Ci _ Zip9946 Lic#S/ZZ66Phane# A-99 116,5 R7/Z <br /> Consultant Sub �!/I/L,/2. Address sT ityAgrw Lic#G 5-770"7 Phone# '6 -7 If S/8y <br /> l _ <br /> GIS Coordinates:X Y Township Range Section <br /> I <br /> WORK TO BE PERFORMED: <br /> [I NEW WELL 1 BORING (GPT,GEOPROBE,HYDROPUNCH,HAND AUGER,O HER*) AOV.ER-_BORE__DjAMETER. <br /> ESTRUCTION (choose type below)�t7 SOIL BORING# <br /> In WELL# <br /> PRESSURE GROUT <br /> In*Other GROUT SPECIFICATIONS 5-?0l4 ~ <br /> COMMENTS: �11�6SdCx Ce��.�rr�T <br /> �I <br /> TYPE OF..WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIC NS Z// <br /> MONETiORING HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS o MULTI-LE;SED: <br /> WELL CASING DIA: <br /> a EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS _<'CH d TYPE OF CASING: p STEEL PVC a OTHER: <br /> a VAPOR/ MUD ROTARY DEPTH OF GROUT SEALF�- TREMIE TYPE TO BE UGERS a HOSE <br /> 1]AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Ves a No (NOTE: MAXIMUM FREE- ALL DEPTH IS 30') <br /> SOIL BORING ©HAND AUGER GROUT SPECIFICATION -'r-. / H D �,4Gk CE�hL�71/r <br /> )KOTHER: WIV1O I a OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or li STOVE PIPE <br /> n� /CONDUCTOR CASIN PROPOS D (if YES,list specifications in comment section) <br /> COMMENTS: ENrC� �1�—/ 8 C�r></ Na r" iL4 1� 70 i 1J Np G:+rld(fT <br /> I! <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRE EMENT OR ENCROACHMENT PERMITS. <br /> 1 48 WORKING HOURS NOTICE REQUIR D FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the wok will be done in accordance with San Joaquin <br /> CountyOrdinance , Ruyes and Regulations,and all applicable California State Laws. <br /> Signed Ik _TitlelCompa yi_ '1 U/� r�lf/l/el/ <br /> Print Nam 1 '` l !��aQ --Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: "ls <br /> WORK PLAN DATED: O —O <br /> Applicatih Accepted By Dae Issued� r Area <br /> Grout Inspection By Date Final impaction By <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ,i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CORS FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 5oZ' g d6 z T�•1 SR# O ID -Ia3 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to Sign permit Encroachment docw <br /> 'I <br /> EHD 29-02-001 <br /> 6122104 <br /> it <br />