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` D <br /> *San Joaquin County <br /> Environmental Health Department I _ <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 I�f CST <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd E�� NST <br /> N0 <br /> * VAR <br /> RT ij,­ <br /> Well hermit Application iSE <br /> RVjCFs <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 /> I Assessors <br /> WELL Location S'/4" L,JCS�' GA&,,j�/ wy Cross Street 644 c.n1n City .S&Ckjon Zip '?,s Parcel# JC/�]0?y0k <br /> PROPERTY �� � �,f� <br /> Owner oh R aZG PS Address_1807 D v —City__��ZQse4[Qn Z p V1�a�Phone# 09' W 6 y'.r'T 8 <br /> C-57 Contractor I//ror,r,�JC_Address )LI/O A�..,.S 4Vc City�ZiP 9ylry9Lic# Phone# �OQ��y7- `b39 <br /> Consultant/Sub Cntr5/ ,r., 6ltvrion,.e,%jtddress /3-24 9Aoykd City .S iaAr» Lic# S'�.f6Z0 Phone# p/(r" 9.2p'3300 <br /> ss3�— <br /> GIS Coordinates:X 6332[x?, M,Y Z�SRSS ,Township Range Section <br /> WORK TO BE PERFORMED- <br /> 0 NEW WELL/ BORING PT,GEOPROBE,HYDROPUNCHAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> ,I SOIL BORING#1C' Q OVER-BORE. DIAMETER <br /> Q WELL# „PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS OG✓rQ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL R// TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: $(Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS DG✓R <br /> ex OTHER: GPT Q OTHER APPROX.BORING DEPTH <'0 ` Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: NEAT C11 Ptn E&M�af-hAT - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinances Rules a ulatio , and all applicable California State Laws. <br /> Signed x Title/Company ODIe C'24 -SC.1C"1 AVS <br /> Print Name <br /> Date 3/9o C <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Sl ";;- C/1^C'%,� <br /> WORK PLAN DATED: 31 D <br /> Application Accepted By ate— Date Issued�Zd/O(' Area <br /> Grout Inspection By I bAAA..&n!, Date ;k Final Inspection By <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 /> So3 d"-o00 36�•oa �� , 312,1* SR# <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit7 Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />