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San Joaquin County ' <br /> 2 - = Envnmental Health Departments no .{� ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 W <br /> IS�O�ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chd UNIT IV <br /> gtlogN� Well Permit Application <br /> AUG ; 0 2005 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This pp ica I is'rii�a�d�� compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> j / �1 f Assessors <br /> WELL Location 1 f70 Cj;(fn, C,+. Imo• Cross Street e,e1�i ��• City Zip ' 5 ZOG Parcel# 1539-0`10-IL <br /> PROPERTY C//� <br /> Owner Mai., Si", "fq• Address 2q$O ",*Ae_))r City. Ac ) Zip %311, Phone#(Z,4) siy3-2c3,/9 <br /> C-57 Contracto1)i Address qsr-, owe QZ , _ City'fVl La Zip 53 Lic# Phone#(4-2 313-5 <br /> Consultant/Sub Cntr Address 4 3r7 Sia c fQ, City Licck{oq Lic#Cnq�IZZrl Phone# (2,,q)L/G7-%ocaCc <br /> GIS Coordinates:X 'y Township Range Section U <br /> WORK TO BE PERFORMED: <br /> EW WELL 1 BORING CPf EOPRO`iBE,H+YDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) C <br /> SOIL BORING# CPT-� Yhre wL C.PT-s, CPT-5 (1( Cry S, 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> f� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION ©AIR HAMMER/ORIVEN CASING THICKNESS_ V%Z,-, TYPE OF CASING: (]STEEL []PVC ©OTHER: vla <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL I CSO <br /> � TREMIE TYPE TO BE USED: fr<UGERS O HOSE <br /> 0 AIR SPARGEI OZONE $'fUSH POINT(GP or CP ,GROUT SEAL PUMPED: 0 Yes g-Wo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH ��o` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED a (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 /> C <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 - !�!- TitlelCompany of o <br /> Print a Date R- <br /> DEPARTMENT USE ONLY \, <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATEQ: // ✓cuz GS� �s <br /> Appl!cation Accepted By di // /�-"a; rj Date issued �O _ � G _ f <br /> Area `/ 3 <br /> Grout Inspection By f' Sf A Date 531-"15 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 1 SERVICE REQUEST# INVOICE <br /> 7s�/ 5� . .-,& ZZ 75 Z SR# 0043735 <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 /> I <br />