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• • FILE COPY <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/e /11 UNIT IV <br /> U <br /> Well Permit Application <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 /> �� S? Assessors <br /> WELL Location $ 5'0 S. SA Cross Street MA--4641—ftity F?'cA/cY�CAw-'oZip pS33� Parcel# /Q1/7 On <br /> PROPERTY ,/ / <br /> Owner �,40 yOAN U✓ Address 243T 4JA4a MAA1 Cit S%x-'oN Zip/n'? Phone# 983 P <br /> � <br /> C-57 Contractor Gt It dr?C2 Address %So IAr-•IE AVL° City M•�RTNELZIp iSr3 Lic#VSl4SPhone#97S ,315 5740 <br /> Consultant/Sub Cntr 47G /hW"-f-41M Address_///7 LoAIO M4 AVECity /Noy&7a Lic* Phone# S79 PZ2 / <br /> GIS Coordinates:X ,Y ,Township Range 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 /> SLf✓1 )A A SLfM a PRESSURE GROUT <br /> OVER-BORE. DIAMETER <br /> WELL# <br /> p*Other p <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> JFVONITORING 8(HOLLOW STEM DIA.OF BOREHOLEff�tb�'p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA I_` <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS IC// (O TYPE OF CASING: 0 STEEL ItPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL )`/ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH9 D�OLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in corp section) <br /> COMMENTS: SEC /i-rc AS.SAG/A%Es .sugsvlA=xC Za I/ES7.y,f�'y.t pXKpcAf.+ "DA7d Z Z C <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 prepay d this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Iles gulations, and all applicable California State Laws. <br /> Signed x Title/Company /S 7 ¢7G <br /> Print /o?tl� fj'fi✓E-� Dat'—24/. <br /> DEPARTMENT USE NLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: o/pZ <br /> WORK PLAN DATED: ;Z - 8 v <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By e <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 /> 2qS 29 1 ! 3 b o SR# (� 3n Lf <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encr went doc_ <br /> EHD 29-02-001 1 �� _ . _� 1 <br /> 6/22/04 ��J <br />