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FILE COPY <br /> r - San Joaquin County- --- - - �- <br /> Environmental Health Department �, S <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 �MMG ION <br /> (209)468-3449 Fax: (209)468-3433 Web: .sjgov,orglehd p <br /> ` rhe IT V <br /> QLr •o�� Well Permit Applicati n --o ' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRC M 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 iahce wtif an <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Cross Street County.Environimental Health Department. A. G,,. <br /> Assesso�ry <br /> WELL Location i�33 tt,5est C�,o.,s� �.r n� city Zip IS2 #CG Parcef <br /> S.. ��cact� <br /> PROPERT'.�////7��� A0 p f <br /> Owner /S c_c Address QC> Dom 1�p7 City Zip SZd Phone# 6-R)14S—5g7_1 <br /> C-57 Contractor_ Fa.7_ Address °?qoor r A.,eity C,,kg,' Zipj57bS Lic#Ljyj_q�Phone* o <br /> Consultant l Sub Cntr A a r= Address Inn City Lic# /BCJ 227 Phone# (2:21)�Ce'l (p <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,'NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> Q SOIL BORING OVER-BORE. DIAMETER <br /> # � / ©PRESSURE GROUT <br /> 7OE.thI-,L <br /> rGROUTSPECIFICATIONS <br /> COMME <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING HOLLOW STEM DIA.OF BOREHOLE_&-,5`' a M LTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:_Z� <br /> ©EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS ` TYPE OF CASING: O STEEL PVC D OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL__1_I r TREMIE TYPE TO BE USED: *UGERS j]HOSE <br /> Q AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING G HAND AUGER GROUT SPECIFICATIONS Por a td V <br /> 0 OTHER: a OTHER APPROX.BORING DEPTH 5 r BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED vi o (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRE 1-MENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIR D FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the wok will be done in accordance with San Joaquin <br /> County Ordi ces/Rules and Regulations,and all applicable California State Laws. /� <br /> Signed x f`l- Title/Comps y_ -C_* �ggt o4i5� ,�1G� <br /> Print Na e -� Date 9-0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Dae Issued �'���0 —Area—" <br /> Grout Inspection By hate 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 CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> yZ j <br /> 07 � , SR# <br /> C-57� WCC WAIVER M _ C-57 Letter of Authorization to iyn permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />