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.....T <br /> nn ro \17 <br /> WELL PERMIT APPLICATION FG<M <br /> } 1 <br /> ION <br /> SAN JOAQUIN COUNTY �'�1 i�,u� <br /> �- �LH�r� ��1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) 1� <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 MAY 2 5 2004 <br /> (209) 468-3449 ENVIRON <br /> MEPJT tI_"Li N <br /> _ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMITZSE t r„`- ; <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 co'hfdfi �with San- <br /> _Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> y ( Assessor's <br /> WELL Location 110Cross Street �a- _City_!9ak Zip %wParcel#, <br /> PROPERTY Owner�1\�& jj 4 MeA(VA0 AddressjlD Lb O F_j 7iart��_r.L)- _—C! Tip L�Phone#!/�J�Q P.3�f <br /> C-57 Contractor Address 1�1 Ciiy �?�Zip%2ftLic#L3Ad,;tPhone# <br /> Consultant/Sub Cntr (Sl AddressLic# ft Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED, <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION(choose type below) <br /> SOIL BORING# 1 - 3 D OVER-BORE <br /> WELL# L` 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: �h(l 1 <br /> .COMMENTS �� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> t,a MONITORING n HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?D MULTI-LEVEL?U WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS tN, <br /> CASING: D STEEL D PVC D OTHER. <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEALEMIE TYPE TO BE USED: AUGERS HOSE <br /> AIR SPARGE/O �HANDAUGER <br /> GROUT SEAL PUMPED: D�” TE: MAXIMUM FREDEPTH�S 3u') <br /> SOIL BORING GROUT SPECIFICATIONS: 1- L <br /> OTHER: G{OTHERbgL APPROX.BORING DEPTH []BOLT TRAFFIC OX or D STOVE PIPE <br /> /� ff CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> ` -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> 6-1 CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Or ' ances, Rules and Regulations, an all applicable California State Laws <br /> Signed x Title/Company a <br /> rint Name Y Date <br /> DEPARTMENT USE ONLY <br /> `,SITE MAP IN UNIT IV FILE,ADDRESS: �tol 7 � '2p SO <br /> WORK PLAN DATED: S"2 -O <br /> Application Accepted By Date Issued 6-2_7 -O LL Area 04, <br /> JGrout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> v <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> �1 PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3el6e -r <br /> C-57_V- WC ✓-WAIVER C-57 Letter of Authorization to sign permitAA Encroachment doc 8/29/02 <br />