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�r, �"N.�r� San Joaquin County <br /> = i Environmental Health Department <br /> SITE <br /> { AUG 1 3 20 <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/�� <br /> P RMITISERVICES�IT IV <br /> Well Permit Application . / <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M I <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 /> , -4- Assesso <br /> WELL Location /6/-7kQ ��(� ll S� Cross Street waIYWy City�qvi _Zip Parcet#rs 7-/5 <br /> 6 <br /> J <br /> PROPER L n/► I ! phone# <br /> Owner U��I r Ud(J dress 11(, �N�$'f- City-&, Zips ,l Q / <br /> C-57 Contractor(""p, / Address 3b3 10mu- j..City Lic#�W�bne# ! G (D/ 3 1169. <br /> Consultant/Sub Cntr �/�� Address ��/'l -2e City �O�o�a�Phone# E� <br /> GIS Coordinates:X Y Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> WELL# I D PRESSURE GROUT <br /> D Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /r <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE_YL D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION r D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO B SE UGERS -. D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes o (NOTE: FPA MUM F E L DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH 57)�- 166. D BOLTE TRAFFI BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 c ify that 1 have prepared this appl' anon and that the work will be done in accordance with San Joaquin <br /> County Olr i ances, Rules and Re io nd all applicable California State ws. <br /> Signed x Jitle/Company " <br /> Print Name Date Q <br /> DEPARTMENT USE ONLY �/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1<?I� A) " ,•0u-z-oQ <br /> WORK PLAN DATED: it <br /> Application Accepted By Date Issued ( Area ©�" <br /> Grout Inspection By Date Final Inspection B - S ?�D)te <br /> r" <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2-q01 �?l 2O"5 1 8-t3 SW 3 <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/12/04 <br />