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l�vF PY <br /> San Joaquin County I/3 <br /> Health Department �v �- TE D East Weber Avenue, 3rd Floor, Stockton,CA 95202 E f VIM Pt 9b209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd //t(yn�,*- 'O't'Environmental <br /> Well Permit Application PFA- ^^�� <br /> UI�ES <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <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 /> sso so�Ciip933DAsse <br /> WELL LocationParceg %y Pj It <br /> 11 /6775 S <br /> POP <br /> OwnnerE r ole 4/°f/res Address aY City G4'°' // ,Zip f.f3JOPhone# 6-9) ?1- f-"/ <br /> C-57 Contractor e4rsu /e s� /0- Address �E z Orrcc l i.s/G City.�•verts L7'Zip STY2 Lic# S/s Phone# f4 <br /> kap �sYY9F �E/-mss <br /> Consultant/Sub CnU f� LAddressJ��°�r�� / City Ln^�!o°'a Lilt Phone# / <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> )KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> p SOIL BORINyGG# DOVER-BORE. DIAMETER <br /> `',WELL# (Z) At -?,2 ..:;7' y-' , a PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS P,ik/ /•fu NSA s.. ea•k /mr.w f- `ff(�tl, l<r�s>ct cat��s_f8' �F � 4.'� „trr tte�J <br /> T <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,HOLLOW STEM DIA.OF BOREHOLE S` MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS JP/° Yd TYPE OF CASING: D STEEL A-PVC E OTHER: <br /> < ' <br /> 0 VAPOR E MUD ROTARY DEPTH OF GROUT SEazr c 4!tN TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> E AIR SPARGE/OZONE E PUSH POINT(GP or CPT)GROUT SEAL PUMPED:'A Yes a No (NOTE: MAXIMUM FREE- ALL DEPTH IS 30') <br /> aSOIL BORING aHAND AUGER GROUT SPECIFICATIONS 41/ 1' <br /> ,usu-zz75 <br /> D OTHER:_D OTHER APPROX.BORING DEPTH .[s✓-2?:: OLTED TRAFFIC BOX or Q STOVE PIPE <br /> ,Y CONDUCTOR CASING PROPOSED e, (if YES,fist s1pecifications in comment section) <br /> COMMENTS: srokf .w.a==.�q CG >^ ck._c• Yj- 'f�/s�r1 i .1166'`22 �-Ire'/ / /'c 7f ( / f- fIS/P. <br /> .4YU'23 760 6e �^'�/t.f' e SS �.`/'�.ti �3 1puNf ISi /fxvG .$FecJ"r/ O.O.ZO'�scs-ne�to <br /> NOTE: OFFSITE BORINGS REQUIRE/ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, <br /> Rules <br /> and <br /> Regulations,and all applicable California State Laws. / <br /> Signed x :E11f Title/Company 31°a.f6 C•�® �l 1cCm'CJ <br /> Print Name /,' 4,./ /dr �>:-rv- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 6 V76 ` <br /> WORK PLAN DATED: ,0 5 <br /> Application Accepted By Date Issued -'� 13O'6 Area 46 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ECK# REC'D BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> D Q / SR# QS <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment riot_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />