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�----� <br /> 11nov <br /> WELL'I�ERMIT APPLICATION FMM <br /> SAN JOAQUIN COUNTY c I <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) -' <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 MAY 2 5 2004 <br /> (209) 468-3449 ENVIRONMENT F_ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM/T�SE{��/ <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 cbfi'f{�ki> with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ,�-f /y� Assessor's <br /> WELL Location�7\��Ot'1y� �s�p(/1� S�- Cross Street l City �CY� Zip 'Parcel /U-9) <br /> PROPERTY Owner J�p�q�� S�S�rn (p_&&dress&10 N��Q!arl] 54 City Zip,15�_()H Phone#�b�o l o�3�� <br /> � �} CitZip ( ic#6 C-57 ContractorAddress O <br /> Consultant/Sub Cntr (Sl £: Address <A VV-% , City /( Lic# ti Phone# � <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# I " -3 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications:_AL <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESStNo <br /> CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1EMIE TYPE TO BE USED: AUGERS _ 0 HOSE <br /> 0 AIR SPARGE/O�err�0 PUSH POINT GROUT SEAL PUMPED: 0 YTE: MAXIMUM FRE -FAL:_ DEPTHIS3G'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1- <br /> DOTHER: OTHE APPROX.BORING DEPTH0 BOLT TRAFFIC OX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> 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 antes, Rules and Regulations, an all applicable California State Laws. <br /> Signed x Title/Company 1 e ldY" <br /> Print Name Y Date <br /> 'DEPARTMENT <br /> /USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��vf' 7 - C- 2j�-SO <br /> WORK PLAN DATED: S•2 •O 2 <br /> Application Accepted By Date Issued 6-2-7 "� \ Area 04 d <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE j' PERMIT/SERVICE REQUEST# INVOICE <br /> Z 1 ;Z,0e(( 5725 <br /> C-57_I/— WC ✓-WAIVER C-57 Letter of Authorization to sign permit Encroachment dot 8/29/02 <br />