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qU i . oo San Joaquin County <br /> z� Envir�.,mental Health Department ,,,,,,lr,; SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 - `MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/gic, ', 2 2005 UNIT IV <br /> gC'�oR��P Well Permit Application FNVjp(-)PA1EN HEALTEi <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> SERVICES <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 9-115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location Cross Street City �.�, S� Parcel# <br /> Zip� <br /> PROP <br /> Owner T t' Addresspt. -K �`J� City +�'� Zip - Phone# <br /> Owner <br /> C-57 Contractor 4��� C' �fn Address'-f�� H 2 iZ Cityk�il�{C�zip L ZLic#l��`N' one#%z� <br /> Consultant/Sub Cntr i/�� p Address 5 y S4(w L cy city Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/ BORING Q EOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0'Other / GROUT SPECIFICATIONS <br /> COMMENTS: C-r •S�i'^�h via <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE'(-' MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ti/—TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALlf�r -ee� TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE jJ-PtJSH POINT(GP o CPT ROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 2-SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS rS;'L( ��tt <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x �l1`✓� /✓� V i �y Title/Company �; <br /> wl <br /> Print Name t'! �_ Date 22 S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED-: /5 u h <br /> � n <br /> Application Accepted By Date Issued ZArea <br /> Grout Inspection By Date 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 /> 8Y <br /> 3 50 3 z�9 .��� l 3`� SR# <br /> C-57_ WC -WAIVER_ C-57 Letter of Autho,4111zat n o sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />