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,0 4"` <br /> Ian Joaquin County <br /> y % Enviromental Health DepartmenIc�pp� SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9520 c!!SS VV 6TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or9"MN 5 2006 UNIT IV <br /> A��FORN`P Well Permit Application ENVIRON <br /> hfW NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEERMIT V CESTH <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 /> WELL Location 114 Ci_ OW,(�I-PJf wGW Cross Street i eK w s�4Lw�jI,�1 �� Assessors <br /> I City vZip �152D5 Parcel# ISS-/ZO-I r8 <br /> PROPERTY * 1 /+ 1 <br /> Owner_K4id 111)v� PMT UD _Address .1 MiS',inYl naf 1L City iDY I`- Zip�Phone# /o/`�—$3D-Z3Z0 <br /> C-57 Contractor ,Mmotd CTer&tvitnuuP ddress t 3l 5lw.w lA CityZip 52K Lic#_,ZPhone# 4✓r�-�DD(o <br /> Consultant/Sub CntrAbati(21�'?Qtt yiYDWf.dAl Address St?S151,yxw VA City stkG Lic# WPhone# y� 7-1DO <br /> GIS Coordinates:X _Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NsIEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> jll'SOIL BORING# S 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS AIM TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ZD r TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes V'No (NtjOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS PDf`HaN <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH 2D' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: <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 Ordinan Igs.and egulations, and all applicable California State Laws. <br /> Signed "i/Z`� Title/Company-B.:0f�eofD9ds�IDirer_�1x DF boerAMS <br /> Print Name $2.r A( Date OG'02-D 1p <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ( /h� /' / / <br /> Application Accepted By ` • 'y Q- Date Issued �1 WARS b Area <br /> Grout Inspection By. Date Final Inspection By Date <br /> Destruction Inspection y 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 /> 2�(D I g�1 .00 240257 ifom& /6( SR# ql6crD <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 />