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Dt %an Joaquin County 0 <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd �CGTION <br /> 4trFda II II UNIT IV <br /> Well Permit Application 2 5 2000 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROAMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This 4I <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of SanJoaquinCounty Environmental Health Department. mpliance with San <br /> WELL Location A00 � , lAl aa,the VAUP- Cross Street 0. kl ')0 Cit S+dC -kd ssessors1 3 nr7 <br /> � -� yZiPgS�IJ Parcel# 1 �5� �v' / <br /> PROPEI�';Yx C, I CU✓ II <br /> Owner S51}$ nV00VOAio✓t Address(3SIS -� e p, Cih, 1q.lO40-ZIPAJA Phone# C7007Sa/-/q,13d jJ <br /> C-57 Contracto S Gk2 IDV i t Address363�ccsOLV v� Zip�.��rZLCc# S��one# <br /> Consultant/Sub Cntr DLNA K AddressCd.J 1 tAi r�� CityC-ylCl(At �Ic# Phone# 6a q -5 <br /> GIS Coordinates:X Y ,Township Range 9 Section <br /> WORK TO BE PERFORMED, <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> II WELL I 0OVER-BORE. DIAMETER- <br /> [I*Other <br /> IAMETER[I'Other 0 PRESSURE GROUT <br /> COMMENTS: <br /> GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING j HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S fI0 TYPE OF CASING: <br /> 0 STEEL I PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /a��TREMIE TYPE TO BE USED: f AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS V rt I c..Ick <br /> 0 OTHER: rI OTHER APPROX.BORING DEPTH_ To , 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IJ <br /> _ 1 S I U �Q �. (if YES,list specifications in comment section) <br /> COMMENTS: . V'O F6 Is "C IU�CC <br /> 1 i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify tha4 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin c , Rules i <br /> a gulations, and all applicable California State Laws. <br /> Signed x � Title/Company. psh1v64itold <br /> Print Name _ Ka'AVCtti � 1K('X0.vtI pd 1j I Dale p d6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By, ll 0k,,Lk Date Issued OCA a 9no <br /> Grout Inspection By (�f� -�(� DateL�� Final Inspection By Date'ytl/`r/"1/l7b� <br /> Destruction Inspection By Date' <br /> 5COMMENTS/CONDITIONS:C . Q L Q - # . m t7i9 S <br /> NG ONLY: AID# <br /> FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> sR# daq�5;8 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />