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FILE <br /> COPY <br /> ,pan Joaquin"Coun �� <br /> a.' Environmental Health Department ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockt an,CA 95202 NOV ._ 9 2TIGATI4N <br /> (209)468-3449 Fax: (209)468-3433 Web: .sjgov.org/ehd <br /> UNIT IV <br /> �q • <br /> 0.;•�, <br /> o� Well Permit Application ENVIRONMENT HEALTHPERMIT/SERVICES <br /> I� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRC M DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install th 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 C unty Environmental Health Department. <br /> ` Assessors <br /> WELL Location 5T—Cross Street PlAity, Zip Parcel# 12S �yA <br /> 6 <br /> I <br /> PROPERTY ���� f p9� 9 Phone#ZO'? /r/ XIA� <br /> Owner Itl. k Address ���47��� Ci O� Zi pZ� <br /> C-57 Contractor '' ,*-J�fr �044- Address03dfAl/!rllJ�" w, Ci y/�LLw^/ Zip7�ic#�� Phone# �6� 671Z <br /> Consul .r !SubCntr 62Z//LL L �!//�.� Address fo-73 '��� G�ity 4 Lic#Lg'77477 Phone#_ ? 72 <br /> GIS Coordinates:X 'y Township Range Section <br /> IM . <br /> WORK TO BE PERFORMED. <br /> EW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,O HER*) a DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# /LI� 117 / f Jj �_-_S - 0 PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: /l/6--,?,/ Al"6 'r' SSS G 60 14 <br /> TYPE OF.WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> "MONITORING HOLLOW STEM DIA.OF BOREHOLE a M LTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:el <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS-! l TYPE OF CASING: []STEEL XPVC p OTHER: <br /> VAPOR I aMUD ROTARY DEPTH OF GROUT SEAL s TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> []AIR SPARGE/OZONE (]PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes a No [NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS �/� "7 0 JfJ 5.4c.4_- <br /> p OTHER: p OTHER APPROX.BORING DEPTH '16OLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_ (if YES,list specifications in comment section) <br /> COMMEITS:Ib rH d� S$�L /5 4-6 = (a0 Ile — <br /> II , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIR D FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the wok will be done In accordance with San Joaquin <br /> County`Ordinances, ule and Regulations, and all applicable Calif r Ila State Laws. <br /> Signed x.I`. Title/Company C1 Ifl/G CJ�✓�s L� � <br /> Print Name <br /> G �i �`r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: C;2,3l-5 A-�• GDS <br /> WORK PLAN DATED: <br /> Ir <br /> i <br /> Application Accepted By Dae Issued l ' Area <br /> Grout Inspection By Date Final Inspection By1 to Z D <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> 'h <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> r <br /> (03 r_q SR# 0 <br /> C-57 WCC WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc <br /> I <br /> EHD 29-02-001 <br /> 6122/04 II <br /> E <br /> it <br />