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�. San Joaquin County <br /> Environmental Health Department MA SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 �V�I1 dWf ION <br /> ` (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/elld ENVIRONMPlREAY-H <br /> •''Qcrfi�;:, k� Well Permit Application PERM!:ASF P IGEN _ <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 /> II / Assessors <br /> WELL Location G+gGO�n S�leG f Cross Street G e Hw_City S G 70h Zip 7_5:206 Parcel# <br /> PROPERTY 1 / <br /> Owner Gi71 Y o r StOG�TOn Address 2 E. GvGbrrr fJvC. City St G n Zip .70 Phone# 2�7.37" 3 <br /> C-57 Contractor WrOAeX -'-„G. Address //0 Ada"I Avc• City S Le Zip 4y.1'/zLic#�z_Phone# �p-�y7 6L39 <br /> Consultant/Sub CntrSA&n., ddress/314 AcVkc/ CityS Lic#J/r6,20 Phone# 7/9- 7.2&1 3300 <br /> S <br /> GIS Coordinates:X G 33-2 7614 V,Y ,3 9 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> &SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# , PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS L)GtirQ <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS AM TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL fy& TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE $PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> gSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS OtyQ <br /> ,OTHER: GoOT 0 OTHER APPROX.BORING DEPTH SO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: C-04�___L'11- r�12C" 1— <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, les a d egula " s, and all applicable California State Laws. L _/ <br /> Signed x Title/Companyrqc"— <br /> Print Name Date 3Z9 '� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: SI Sr C4^,ex A 47C"% 1/k-' <br /> WORK PLAN DATED: !S 31 O 5— <br /> Application Accepted By V--k%nne-r Gam_ Date Issued S I 06 Area <br /> Grout Inspection By Date _ 2 O-6 Final Inspection By Date <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/SERVICE REQUEST# INVOICE <br /> a <br /> S R# <br /> o a 3vat' <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc{L <br /> EHD 29-02-001 <br /> 6/22/04 <br />